Nurse Practitioner exam
systemic lupus erythematosus
"Butterfly" facial rash and Raynaud phenomenon in a young female
kernig sign
"Make curved straight"-patient supine, bend leg holding at knee and straighten leg up. Severe pain in back and neck is positive
hemoglobin
(f) 12-16 ; (m) 14 - 18
hematocrit
(f) 37-47% ; (m) 42-52 %
Norwegian scabies
- Immunocompromised patients can present with this "crusted" presentation, with thick scaly plaques over most of the body, which is often misdiagnosed as psoriasi
primary prevention
-addresses the needs of healthy clients to promote health and prevent disease with specific precaution
tertiary prevention
-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functionin
secondary prevention
-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health statu
BB example
-lol
neonate age
0-28d
(DPP-4) inhibitor A1c drop
0.6-1.4%
(SGLT2) expected a1c drop
0.7-1%
children 6-11 mo traveling outside US immunization
1 dose MMR they normally dont start til 12 mo but this is to reduce importation of MMR this shot doesnt count in the sched though
anemic blood loss
1+L loss in an adult to drop Hb significantly I unit of PRB=1/2L blood=3% HCT uncommon cause of anemia in primary care
GLP-1 Agonist A1c expected
1-2%
Sulfonylurea (SU) expected a1c
1-2%
Thiazolidinedione A1C dec
1-2%
metformin anticipated A1C reduction
1-2%
toddler
1-2yr old
aortic regurgitation
1-3/4 high pitch diastolic 3rd LICS men rheumatic HD
mitral stenosis
1-3/4 low pitch late diastolic heard at apex rheumatic HD
physiologic murmur findings
1-3/6 systolic LSB but also precordium no radiation innocent
mitral valve prolapse
1-3/6 systolic honking quality heard at apex minor thoracic deformities (ex: pectum excavatum) Sometimes chest pain
atrial septal defect (ASD) uncorrected
1-3/6 systolic ejection murmur at pulmonic w/o sx until middle age then present with HF
grading for diastolic murmurs
1-4 not 1-6 because they are not loud enough to reach 5.6
In an immunocompetent adult, the length of incubation for the influenza virus is on average:
1-4 days Adults pass the illness on 1 day before the onset of symptoms and continue to remain infectious for approximately 5 days after the onset of the illness. Children remain infectious for 10 or more days after the onset of symptoms and can shed the virus before the onset of symptoms. People who are immunocompromised can remain infectious for up to 3 weeks.
aortic stenosis findings and dx
1-4/6 Systolic ejection murmur heard in the 2nd-3rd right interspace close to the sternum radiates to carotids usually congenital if younger rheumatic maybe if adult
mitral regurgitation
1-4/6 high pitch systolic murmur RLSB radiates to axilla, lateral displaced PMI Ischemic heart disease, endocarditis, RHD
grading for systolic murmurs
1-6 from barely audible to audible with steth off the chest
kawasaki disease age
1-8
early adolescence
10-13
3-4yo intelligible to others not in family
100% 50% at 19-21 mo
measles incubation and transmit
10=14d transmit for 1 wk prior to rash up to 2-3 wks after rash appears
shrug your shoulders CN
11
kawasaki disease sx
11d acute phase: high fever >5d, exanthem on trunk, flexor regions, perineum, strawberry tongue, bilat conjunct, edema hands and feet
stick out your tongue CN
12
when mama papa speak
12 mo
when kid walks
12-15 mo was a post ww2 study in Mass among mainly euro decent (irish) these kids tends to do this later than asian and african ancestry
most common time for anemia in peds
12-30 mo bec depletion of birth iron stores usually lasts until 6 mo mat iron depletion too
back seat sitting until what age
13yo
middle adolescence
14-17
rubella incubation and transmission
14-21 d transmit for <1 wk prior to rash up to 2 wks after rash appears we want to avoid transmit bec of unborn child so preg women, not as much the patient. Teratogenic
<60yo HTN goal general
140/90
>60yo HTN goal general
150/90
screen for autism age
18 and 24 mo
late adolescence
18-21
use timeout at what age
18-24 mo 18 introduce 24 start using
when 50% speech understoof
19-21 mo
Beta 1 and 2 location
1=heart 2=airways
HTN retinopathy grades 1 and 2
1=long poorly controlled HTN, reversible if tx HTN. narrow terminal branches 2=same but with more local constriction but still no vision changes
ex of significant anticholinergic effect
1st gen antihistamine Benadryl etc
acute cough mgmt
1st gen antihistamine/decongestant bromfed (bormpheniramine with peudoephedrine)
Neuroleptics for HA
1st gen antipsychotics prochlorperazine (Compazine) and promethazine (Phenergan) occasionally adjunct bec of antiemetic effect highly sedating cause EPM so limit use to 3 days/wk could use zofran, more expensive could use reglan for GI but still has EPM risk
most accurate source of EDD
1st trimester US
how much grams of topical ointment
2 g for hands, face, head, genitals (28g BID/1wk) 3g for arms, ant or post trunk (42g BID/1wk) 6g for 1 leg (84g BID 1 wk) 30-60g for entire body (420-840g BID 1 wk)
CCB example
2 subclasses Dihydropyridine: Amlodipine NonDHP: Diltiazem
peak HAV infectivity
2 wk period before onset of jaundice or elevation of liver enzymes
when stop adjust age calculation for pre term
2 yo
highest risk for exacerbate COPD and death
2+ exacerbations in the last yr FEV1 <50% and/or hospitalization for COPD in last yr
forward facing carseat
2+yrs or outgrown
aortic sclerosis
2-3/6 systolic ejection murmur 2nd RICS benign thickening
mono incubation
20-50 d no contact sports
cervical cancer screen
21-29 - PAP every 3 years, 30-65 PAP every 3 years or PAP + HPV testing every 5 years
You see a kindergartner with impetigo and advise that she can return ________ hours after initiating effective antimicrobial therapy.
24 hours
tetanus shot
3 dose booster 10 years if adult, need the 3 but 2 can be Td instead of Tdap if minor wound and unclear vax hx give tet vax if other wounds too give tet with immunoglob (TIG)
post infxn cough
3-8wks following sx use atrovent
normal Vaginal pH, discharge, odor, microscope
3.8-4.2, white/clear, absent, lactobacilli
cause of COPD flare
30-50% bacterial also could be smoke, pollution, virus etc
PPI education
30-60 min before meal for max pH control before first meal of a day also its associated with B12, Ca, Mg, Fe malabsorption and poss inc fracture and C.Diff diarrhea risk If pt does not respond to PPI, they should be referred when come off PPI after more than a few months, get rebound Sx. Wt loss recc HOB elevate avoid meal 2-3hrs before bedtime if nocturnal GERD food that are known to trigger should be minimized
additional kcal over baseline for preggo calcium folic acid iron
300 1000-1500mg/d diff for if hx if hgb <11
Oral products for migraines
30min- 1 hr to kick in best suited from slow onset and minimum GI issues use ASAP least expensive and facilitates patient self care
Tension type HA duration
30min-7d (usually 1-24 hrs)
Tension type HA diagnosis
30min-7d (usually 1-24 hrs) with 2+ of the following: pressing, nonpulsatile pain mild to mod intensity usually bilateral Nausea, photophobia, or phonophobia F:M 5:4
early term preg
37-38+6d 37 wk is when lung mature enough
full term preg
39-40wk+6d
Indicate the appropriate course of action (head CT scan, head MRI, or neither) for each of the following patients: 39. A 45-year-old man who presents with a sudden, abrupt headache. Upon questioning, he appears somewhat confused with decreased alertness to his surroundings. 40. A 48-year-old woman with a history of breast cancer who presents with 3 month history of progressively severe headache, and bulging optic disk. 41. A 24-year-old man who presents in the ED following a motor vehicle accident. He exhibits confusion and falls in and out of consciousness. 42. A 57-year-old woman with a prior history of a brain tumor that was removed 8 years ago. She complains of headaches that have been increasing in frequency and intensity over the past month. 43. A 37-year-old man diagnosed with cluster-type headache that is alleviated with high-dose NSAIDs
39. CT scan 40. MRI 41. CT scan 42. MRI 43. Neither
HTN retinopathy grades 3 and 4
3=DBP>110, now add striate hemorrhages and soft exudates and potential for vision change, permanent 4=DBP>130, papilledema and vision change and permanent this is an EMERGENCY by the way
no solids for baby before..
4 mo
breastfed baby usual number of BMs/day
4+
reaches for toy with one hand and recognizes familiar people and objects at a distance
4-6 mo
when vax HAV before travel
4-6 wks if going to high rate country
Migraine without aura diagnosis
4-72 h and 2+ of following: unilateral though occationally bilat pulsating, mod to severe aggrivate by normal activity during HA note 1+ N/V/photo/phono F:M 3:1 fam hx: 70-90%
Migraine without aura duration
4-72 hrs
perimenopause onset, duration
40-45yo 4yrs avg
vit D recc peds
400 IU daily formula, milk
later term preg
41wk-41+6d
post term preg
42+wk
how often get a1c
4x if not meeting goal 2x if ok goal <7%
Reccomendation length of CAP Tx
5 days with evidence of increasing stability, afebrile 48-72 hrs prior to ABX discontinuation so 5-7d is good
5yo remember
5 wd sentence draw square
school age
5-12
low dose CT for smokers
55-74yo >30yr Pack hx <15 yrs since quit
actinic keratosis treatment
5FU cream (topical chemo) and use liquid nitrogen
age to start flu vax
6 mo
total WBC
6-10 thousand is NL
babbles mamama bababa transfer hand to hand
6-8 mo
responds to own name and sits without support
6-8 mo
vocalizes ah and oh and lift head briefly when positioned on tummy side to side
6-8 wk
6yo remember
6wd sentence draw triangle
puff out your cheeks CN
7
% tried Etoh by senior year % MJ %cig % Rx for non medicinal use
70% 50% 40% 20%
newborn visual range
8-12 in
normal MCV
80-96
tap water temperature
<120 degrees 5 min at 120 =3rd degree burn
LAIV precaution
<2 >49 2-17 and receiving aspirin hx severe allergic reaction preggo immunocompromised 2-4 with asthma or wheezing episode in the last 12 mo influenza antiviral med in the last 18 hrs
high ABX resistance
<2 >65 daycare prior ABX in the last month prior Hosp in past 5 days comorbidites immunocompromise
mild acne dx and tx
<20 comedones <15 inflammatory lesions <30 total topical retinoid alone condiser topical Abx and/r benzoyl peroxide
CD4 count for ARV
<350 needs ARV at least
COC, patch, ring eligibility
<40 <35 ok >35 ok but smoking can cause clots
a1c goal low hypo risk normal DM older frial
<6% <7% <8%
who absolutely gets ABX for AOM
<6mo Severe non severe but Bilateral 6-23 mo
fundal height
=gestation from 20-35 wks
BV microscope
>20 clue cells few or no WBC
severe acne dx and tx
>5 cysts total comedone >100 total inflammatory lesion count >50 or >125 total oral Abx with topical retinoid if not working accutane for larger painful cysts consider steroid inj
when IZ for herpes zoster
>60
clinical presentation ACS in elderly
>75 dyspnea neuro-syncope, weak, confusion CP or pressure
how use insulin in type 2
>9% with sx (polys) could be a short course to help achieve normal if impaired insulin release as a result of hyperglycemia when >_2 meds are inadequate when acutely ill (type 1 and 2) to keep 140-180 Bg
A first-line prophylactic treatment option for the prevention of tension-type headache is: A. nortriptyline. B. verapamil. C. carbamazepine. D. valproate.
A
An oral antimicrobial option for the treatment of methicillin-sensitive S. aureus includes all of the following except: A. amoxicillin. B. dicloxacillin. C. cephalexin. D. cefadroxil.
A
Jason is a healthy 18-year-old who presents for primary care. According to his immunization record, he received two dose of HBV vaccine 1 month apart at age 14 years. Which of the following best describes his HBV vaccination needs? A. He should receive a single dose of HBV vaccine now. B. A three-dose HBV vaccine series should be started during today's visit. C. He has completed the recommended HBV vaccine series. D. He should be tested for HBsAb and further immunization recommendations should be made according to the test results.
A
Of the following, which is the least likely bacterial source to cause meningitis? A. colonization of the skin B. colonization of the nose and throat C. extension of acute otitis media D. extension of bacterial rhinosinusitis
A
Peak infectivity of persons with hepatitis A usually occurs: A. before onset of jaundice. B. at the time of maximum elevation of liver enzymes. C. during the recovery period. D. at the time of maximum disease-associated symptoms.
A
Prophylactic treatment for migraine headaches includes the use of: A. amitriptyline. B. ergot derivative. C. naproxen sodium. D. clonidine.
A
The mechanism of action of triptans is as a(n): A. selective serotonin receptor agonist. B. dopamine antagonist. C. vasoconstrictor. D. inhibitor of leukotriene synthesis.
A
When evaluating a patient with acute headache, all of the following observations would indicate the absence of a more serious underlying condition except: A. onset of headache with exertion, coughing, or sneezing. B. history of previous identical headache. C. supple neck. D. normal neurological examination results.
A
Which of the following signs and symptoms most likely suggests meningitis cause by N. meningitidis? A. a purpura or a petechial rash B. absence of fever C. development of encephalitis D. absence of nuchal rigidity
A
Which wound presents the greatest risk for tetanus infection? A. a puncture wound obtained while gardening B. a laceration obtained while trimming beef C. a human bite D. an abrasion obtained by falling on a sidewalk
A
When considering an adult's risk for measles, mumps, and rubella (MMR), the NP considers the following: A. Patients born before 1957 have a high likelihood of immunity against these diseases because of a history of natural infection. B. Considerable mortality and morbidity occur with all three diseases. C. Most cases in the United States occur in infants. D. The use of the MMR vaccine is often associated with protracted arthralgia.
A The MMR vaccine contains live but weakened (attenuated) virus. Two immunizations 1 month apart are recommended for adults born after 1957 because adults born before then are considered immune as a result of having had these diseases(native or wild infection); vaccine against these three formerly common illnesses was unavailable until the 1960s
Identify whether the item has the characteristics of 23-valent pneumococcal polysaccharide vaccine (PPSV23) or 13-valent pneumococcal conjugate vaccine (PCV13). A. Routinely used in early childhood ________ B. Use is associated with greater immunogenicity ________ C. Routinely used in all well adults age 65 years or older________ D. Not licensed for use in children younger than 2 years of age________
A = PCV13 B = PCV13 C = PPSV23 D = PPSV23 The pneumococcal polysaccharide vaccine (Pneumovax PPSV23) contains purified polysaccharide from 23 of the most common S. pneumoniae serotypes. Pneumococcal conjugate vaccine (Prevnar, PCV13) contains purified capsular polysaccharide from 13 serotypes of pneumococcus and is used in select adult populations, particularly the immunocompromised. Use of PCV13 is associated with greater immunogenicity when compared with PPSV23, but it does not provide protection against as many pneumococcal serotypes, and is routinely used in childhood. PPSV23 is not licensed for use in children younger than age 2 years.
histamine
A chemical released by the body during an inflammatory response that causes the blood vessels to dilate
Multiple Sclerosis
A chronic disease of the central nervous system marked by damage to the myelin sheath. Plaques occur in the brain and spinal cord causing tremor, weakness, incoordination, paresthesia, and disturbances in vision and speech Sx occur acutely, worsen over a few days, can last weeks, followed by period of partial to full resolution Descending weakness, Charcot's sign (intention tremor, nystagmus, scanning speech)
rheumatoid arthritis
A chronic systemic disease characterized by inflammation of the joints, stiffness, pain, and swelling that results in crippling deformities
active immunity
A form of acquired immunity in which the body produces its own antibodies against disease-causing antigens.
epididymis
A long, coiled duct on the outside of the testis in which sperm mature.
cauda equina
A patient presents to the ER with saddle anesthesia and loss of bowel and bladder function. What is the most likely diagnosis?
interferon
A protein released by infected cells, usually in response to the entry of a virus, that has the property of inhibiting virus replication by attaching to uninfected cells which stimulates the uninfected cell to synthesize another antiviral protein that inhibits viral replication.
quadrivalent MMR, what is it?
A quadrivalent vaccine, protecting against measles, mumps, rubella, and varicella (chickenpox), is also available and usually used to immunize younger children.
acute coronary syndrome
A term used to describe a group of symptoms caused by myocardial ischemia; includes angina and myocardial infarction.
retinoblastoma
A young child has loss of the red light reflex. What is the diagnosis? white instead of red
ABCDE skin- malignant melanoma
A-asymmetric B-border (irregular) C-color D-diameter (>6mm) (pencil eraser) E-evolving moles (new or changed) E-Elevated 2+ = biopsy/excision to confirm dx and additional assessment and intervention
phenytoin drug interactions
A. Phenytoin increases theophylline clearance by increas ing cytochrome P-450 (CYP 450) enzyme activity. B. When taken with other highly protein-bound drugs, the free phenytoin concentration can increase to toxic levels. C. Phenytoin can increase the metabolic capacity of hepatic enzymes, thus leading to reduced drug levels.
question stem: First
ABC, airway, breathing, circulation what is the priority
Syphilis tx
ABX dictated by stage
high risk Qs for pneumonia
ABX in the last 3 months, >65, exposure to daycare, etoh, medical comorbidities, immunosuppress
best tolerate HTN drugs
ACE/ARB/CCB
HTN with CKD 1st line
ACEI or ARB
clinicL decision making process
ADPIE Assessment- subjective-health hx HPI, objective- PE, available diagnostic results Diagnosis- analyze assessment data to determine working dx, keep in mind common dxs Plan- plan of care and prescribe intervention to attain expected outcome Implementation Evaluate- post diagnosis. eval of pts attainment of tx goals and keeping in mind need to adjust
quad screen
AFP-protein produced by fetal liver uE3- protein produced in placenta and feta liver hCG-hormone from placenta Inhibin A- hormone from placenta NTD=inc AFP, rest normal Trismony 21=Inc INhibin and hCG, the rest is dec
nonproliferative diabetic retinopathy SX
AKA background retinopathy microaneurysms maybe bleeding maybe macular edema
Giant Cell Arteritis
AKA temporal arteritis autoimmune vasculitis most common in patients 50 to 85 years old; average age at onset is 70 years. systemic disease affecting medium-sized and large-sized vessels also causes inflammation of the temporal artery Inflammation and swelling of the arteries causes decreased blood flow and its associated symptoms. The swelling normally affects just part of an artery with sections of normal artery in between. Extracranial branches of the carotid artery are often involved; this often results in a tender or nodular, pulseless vessel, usually the temporal artery, accompanied by a severe unilateral headache. On examination, the temporal artery is occasionally normal, however. temporal artery granulomatous vasculitis; ipsilateral blindness (ophthalmic artery) can cause vision loss secondary to vasculitic occlusion and involves the arteries to the optic disk
ANCC vs AANP tests
ANCC-FNP-BC. more on professional issues. 37% on foundations of Advanced practice. 17% on professional practice. 46% on independent practice- health promo and ebp and illeness and disease mgmt. 145 q on clinical content, 30 to professional issues AANP-FNP-C, 35% assessment, 24% dx, 22% plan, 17% eval. When people do poorly, assessment is lowest score. 2.9% prenatal, 14.1% peds, 17.8% adolescent, 38.5% adult, 20.7% gero, 5.9% frail elderly 85% pass the test. AANP- 15 hrs CE prior to retest need recert 5yrs. need practice hrs +CE
Statin algorithm if no ASCVD, no LDL>190 and no DM
ASCVD >7.5 with other Qs? yes? mod to high no? less clear
lab finding alcohol abuse
AST ALT elev 1-3x resolve with sober AST>ALT if nothing else other than ETOH with liver (would be opp with Hep) mild macrocytosis- resolve with sober isolated hypertriglyceridemia
do I need to test for HBV Ab after immunization
About 90% to 95% of individuals who receive the HBV vaccine develop HBsAb (anti-HBs) after three doses, im- plying protection from the virus. As a result, routine testing for the presence of HBsAb after immunization is not rec- ommended. HBsAb testing should be considered, however, to confirm the development of HBV protection in individ- uals with high risk for infection
TIA risk factors
Afib, CAD, the pill
Microcytic, hypochromic anemia with NL RDW DX and next step
Alpha or beta thalassemia minor (trait) Alpha at risk: Asia and africa (AAA) Beta at risk: Africa, Mediterranean, Middle East (BAMME) small pale cells that are all around the same size but lots of them (inc RBC) next step: Hb electrophoresis
Dementia etiology
Alzheimer-50-80% Vascular-20% Parkinsons-5% Misc
initial tx AOM if ABX: 1st line
Amox or Augmentin Cefdinir with PCN allergy longer days for younger
ABRS ABX tx 1st and 2nd line
Amox-Clavulanate 500mg/125mg PO TID or 875mg/125 mg PO BID (better cuz Augmentin tough on stomach) (Amox for DRSP, Clav inhibit beta lactamase) 2nd Amox-Clavu 2000mg/125mg PO BID or Doxy 100mg PO BID or 200mg POD (Doxy is inexpensive, thats why here, but has DRSP risk) (also preg risk cat D) If beta lactam allergy Doxy (no DRSP so we should use this if no risk) Levoflox (flouroquinolone) (DRSP coverage) Moxiflox (flouroquinolone) (DRSP coverage)
mono and which ABX should not be used
Amoxicillin rash
positive antinuclear antibody titer
An abnormal titer of antinuclear antibodies occurs in 95% of SLE
osgood-schlatter disease
An active 13-year-old boy has anterior knee pain. Tibial tubercle pain Patients report pain that is exacerbated by running, jumping, and kneeling activitie
polymyalgia rheumatica
An elderly female presents with pain and stiffness of the shoulders and hips; she cannot lift her arms above her head. Labs show anemia and ↑ ESR.
passive immunity
An individual does not produce his or her own antibodies, but rather receives them directly from another source, such as mother to infant through breast milk onset is within hours but duration is limited, 9 mo or so
excedrin migraine
An over-the-counter aspirin, acetaminophen, and caffeine combination product that is approved for migraine therapy and is effective in tension- type headache. Its advantages include ease of patient access to the product, excellent side-effect profile, and low cost; the product is available as a branded form as well as a less costly generic. Excessive acetaminophen use can lead to analgesic rebound headache.
Lumbar sacral strain intervention
Analgesia PT/exercise Limit physical activity heat or ice
PAD Dx
Ankle Brachial Index value <0.9 doppler ultrasound or MRI to assess blood flow treadmill test arteriogram
Hx of Hep A marker
Anti HAV enzyme normal
Hx Hep C
Anti HCV No HCV RNA NL enz
Chronic disease marker Hep C
Anti-HCV present HCV viral RNA NL or slight elev hep enz
Acute disease marker Hep C
Anti-HCV present HCV viral RNA elev hep enz
amiodarone
Antiarrhythmic
cycloplegics
Anticholinergic agents that paralyze accommodation of the iris of the eye
chlorpheniramine
Antihistamine H1 blocker prototype: Tox: sedation, antimuscarinic
Imiquimod cream
Approved for treatment of external genital warts, actinic keratoses and superficial basal cell carcinoma immunomodulator tricks the body into developing immune response to check the HPV
Parkinsons on off periods
As disease progressed they get on off periods when On, can move with ease when off, difficult to move or uncontrolled movement. common toward the end of a levodopa dosing period. Will do med changes but eventually surgical tx. deep brain stim
ABCDEFG for DM
Aspirin BP Cholesterol and Creatinine Diet Exercise and Eye exam Foot exam Goals
meds to minimize risk of long term systemic corticosteroid
Aspirin for stroke risk PPI for GI protection Bisphosphonate for bone protection
ipratropium
Atrovent Muscarinic antagonist used in asthma
Giant cell arteritis etiology
Autoimmune vasculitis affects medium and large vessels and temporal artery inflammation and swelling leads to dec blood floe and assoc sx 50-85yo
A 48-year-old woman presents with a monthly 4-day premenstrual migraine headache, poorly responsive to triptans and analgesics, and accompanied by vasomotor symptoms (hot flashes). The clinician considers pre- scribing all of the following except: A. continuous monophasic oral contraceptive. B. phasic combined oral contraceptive with a 7-day-per-month withdrawal period. C. low-dose estrogen patch use during the premenstrual week. D. triptan prophylaxis.
B
Hepatitis B vaccine should not be given to a person with a history of anaphylactic reaction to: A. egg. B. baker's yeast. C. neomycin. D. streptomycin.
B
In prescribing prednisone for a patient with Bell's palsy, the nurse practitioner (NP) considers that its use: A. has not been shown to be helpful in improving out- comes in this condition. B. should be initiated as soon as possible after the onset of facial paralysis. C. is likely to help minimize ocular symptoms.
B
In tension-type headache, which of the following is true? A. Photophobia is seldom reported. B. The pain is typically described as "pressing" in quality. C. The headache is usually unilateral. D. Physical activity usually makes the discomfort worse.
B
Parkinson disease is primarily caused by: A. degradation of myelin surrounding nerve fibers. 65. B. alteration in dopamine-containing neurons within the midbrain. C. deterioration of neurons in the brainstem. D. excessive production of acetylcholinesterase in the CSF.
B
The spectrum of antimicrobial activity of mupirocin (Bactroban) includes: A. primarily gram-negative organisms. B. select gram-positive organisms. C. Pseudomonas species and anaerobic organisms. D. only organisms that do not produce beta-lactamase.
B
The use of neuroleptics such as prochlorperazine (Compazine) and promethazine (Phenergan) in migraine therapy should be limited to less than three times per week because of their: A. addictive potential. B. extrapyramidal movement risk. C. ability to cause rebound headache. D. sedative effect.
B
You perform an extraocular movement test on a middle- aged patient. He is unable to move his eyes upward and inward. This indicates a possibility of paralysis of CN: A. II. B. III. C. V. D. VI.
B
You see Harold, a 25-year-old man who recently had multiple sexual encounters without condom use with a male partner who has chronic hepatitis B. Harold provides documentation of receiving a properly timed hepatitis B immunization series. In addition to counsel- ing about safer sexual practices, you also advise that Harold: A. needs to repeat his hepatitis B immunization series. B. receive a single dose of HBV vaccine. C. be tested for hepatitis B surface antibody (HBsAb). D. should receive hepatitis B immune globulin (HBIG) and a single dose of the hepatitis B immunization series.
B
Which of the following organisms is a gram-negative diplococcus? A. Streptococcus pneumoniae B. Neisseria meningitidis C. Staphylococcus aureus D. Haemophilus influenzae
B Do I need to know these?
Of the following, who is at greatest risk for invasive pneumococcal infection? A. a 68-year-old man with chronic obstructive pulmonary disease B. a 34-year-old woman who underwent splenectomy after a motor vehicle accident C. a 50-year-old man with a 15-year history of type 2 diabetes D. a 75-year-old woman with decreased mobility as a result of severe osteoporosis
B Indications for adults to receive pneumococcal vaccine include a variety of chronic health problems such as chronic lung disease (including asthma), chronic cardiovascular dis- eases, diabetes mellitus, chronic liver disease including cirrhosis, chronic alcohol abuse, cigarette smokers age 19 years or older, malignancy, chronic renal failure or nephrotic syndrome, functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]), immunocompromising conditions or recipient of immunosuppressing medications, select organ transplant, cochlear implants, and cerebrospinal fluid leak. Other individuals for whom vaccination is indicated include residents of nursing homes or other long-term care facilities, and all adults 65 years or older regardless of health status. Consideration should also be given to recommending PPSV23 for Alaska Natives and American Indians ages 50 through 64 years who are living in areas in which the risk of invasive pneumococcal disease is increased.
All of the following patients received pneumococcal vaccine 5 years ago. Who is a candidate for receiving a second dose of antipneumococcal immunization at this time? A. a 45-year-old man who is a cigarette smoker B. a 66-year-old woman with COPD C. a 35-year-old man with moderate persistent asthma D. a 72-year-old woman with no chronic health problems
B Revaccination after 5 years after the first PPSV23 dose is recommended for individuals older than age 2 years but younger than age 65 years who are at highest risk of pneumococcal infection or are at greatest risk of having a rapid decline in antibody levels, including sickle cell disease, splenectomy, chronic renal failure, nephrotic syndrome, immunocompromise, generalized malignancy, or on immunosuppressing medications.
For which of the following patients should an NP order varicella antibody titers? A. a 14 year old with an uncertain immunization history B. a healthcare worker who reports having had varicella as a child C. a 22-year-old woman who received two varicella immunizations 6 weeks apart D. a 72 year old with shingles
B because of high risk of exposure and potential transmission of disease
Maria is a 28-year-old healthy woman who is 6 weeks pregnant. Her routine prenatal laboratory testing reveals she is not immune to varicella. She voices her intent to breastfeed her infant for at least 6 months. Which of the following represents the best advice for Maria? A. She should receive VZV vaccine once she is in her second trimester of pregnancy. B. Maria should be advised to receive two doses of VZV vaccine after giving birth. C. Once Maria is no longer breastfeeding, she should receive one dose of VZV vaccine. D. A dose of VZIG should be administered now.
B done before discharge then the second dose 4-8 wks later
Which represents the most appropriate diagnostic test for the patient in the previous question? A. complete blood cell count with white blood cell (WBC) differential B. Lyme disease antibody titer C. computed tomography (CT) scan of the head with contrast medium D. blood urea nitrogen and creatinine levels
B lyme mimics so does stroke, infxn, and tumors
clavulanate
B-lactamase inhibitors
PPI and anemia
B12 and and Iron malabsorption
HTN at 4th titration or add on
BB
prophylactic tx for HA
BB Metoprolol and propranolol have strongest evidence Antiepileptics like divalproex sodium, sodium valproate, and topiramate Select Antidepressants: tricyclic antidepressants such as nortriptyline and amitriptyline, as well as the selective serotonin norepinephrine inhibitors, including venlafaxine,
Prophylactic meds for migraine HA
BB Tricyclics (triptyline) Antiepileptic nutrition supplements: variety Lithium (spec for cluster) dont use CCB
basal cell carcinoma vs Squamous cell carcinoma
BCC- more common, sun exposed, de novo, papule nodule w/out central erosion, pearly waxy. Tissue destruction risk but low metastatic risk SCC- less common, sun exposed, AK or de novo, red conical hard lesions Greater Metastatic risk: lip, oral cavity, genitalia
DXA osteoporosis
BMD is >2.5 SD of young normal T score <-2.5
DXA normal
BMD within 1 SD of a young normal adult T score at -1.0 and above
tests prior to initiation of contraceptive care
BP before COC, patch, ring bimanual and cervical inspection before IUD
Most common cause of urinary obstruction in men
BPH
eval for pt with new onset mental status change
BUN, Cr Glu Ca Na Hepatic Enz B12/Folate TSH RPR CBC with WBC diff UA, U C&S ECG
clindamycin cream tx
BV
clue cells with alk pH
BV
metro gel tx
BV
spinal stenosis
Back pain that is exacerbated by standing and walking and relieved with sitting and hyperflexion of the hips. bilat leg numb
acute uncomplicated UTI in nonpregnant women tx
Bactrim macrobid if local Bactrim resistance Alternative- FQ
how use insulin for DM1
Basal insulin (long acting) Bolus Insulin (rapid) in response to carb intake post meal and snack
Parkinsons tx
Because there is dopamine pathway alteration, dopamine agonists are used ropinirole (Requip) and pramipexole (Mirapex) are usually the early disease treatment of choice because of less AE Levodopa to minimize sx but high AE and eventually after 5-10 yrs of use get dyskinesia
anxiolytics example and effect
Benzos (Buspirone (buspar) potential to help alleviate hypervigilance assoc with Anx but does not dec worry for quick relief 1st line tx for Anx though is SSRI
DXA
Best measures sites prone to fractures
hyperthyroid intervention
Beta blocker to counteract tachycardia, tremor Usually tx together with ENDO Antithyroid med: Propylthiouracil (PTU) Radioactive Iodine with end result of thyroid ablation or hypothyroid
midrange potency topical corticosteroids
Betamethasone dipropionate, augmented, 0.05% (Diprolene AF cream) Mometasone furoate 0.1% (Elocon ointment)
Super high potency topical corticosteroids
Betamethasone dipropionate, augmented, 0.05% (Diprolene gel, ointment) Clobetasol propionate 0.05% (Temovate) Halobetasol propionate 0.05% (Ultravate 0.05%)
Route of transmission Hep B
Blood, body fluids
Route of transmission Hep C
Blood, body fluids
first generation antihistamine
Brompheniramine (1 brand name: Dimetapp Cold and Allergy Elixir) Chlorpheniramine (1 brand name: Chlor-Trimeton) Dimenhydrinate (1 brand name: Dramamine) Diphenhydramine (2 brand names: Benadryl Allergy, Nytol, Sominex)
inhaled corticosteroids/LABA
Budesonide+formoterol (symbicort) Fluticasone+salmetrol (advair) pref tx for mod and severe persistent asthma dont overdo it though, if asthma well controlled, using a LABA could inc risk of death
herbal prep for migraines
Butterbur CoQ10
Primary hyperparathyroid clinical Diagnosis
By elevated serum Ca confirm elevated PTH Test 24h Urine calcium to determine severity get consultation
A 47-year-old woman experiences occasional migraine with aura and reports partial relief with zolmitriptan. You decide to add which of the following to augment the pain control by the triptan? A. lamotrigine B. gabapentin C. naproxen sodium D. magnesium
C
An 18-year-old man has no primary tetanus immuniza- tion series documented. Which of the following repre- sents the immunization needed? A. three doses of diphtheria, tetanus, and acellular pertussis (DTaP) vaccine 2 months apart B. tetanus IG now and two doses of tetanus-diphtheria (Td) vaccine 1 month apart C. tetanus, diphtheria, and acellular pertussis (Tdap) vac- cine now with a dose of Td vaccine in 1 and 6 months D. Td vaccine as a single dose
C
An impetigo lesion that becomes deeply ulcerated is known as: A. cellulitis. B. erythema. C. ecthyma. D. empyema.
C
Antiepileptic drugs useful for preventing migraine headaches include all of the following except: A. divalproex. B. valproate. C. lamotrigine. D. topiramate.
C
Loss of corneal reflex is in part seen in dysfunction of CN: A. III. B. IV. C. V. D. VI.
C
Physical examination findings in papilledema include: A. arteriovenous nicking. B. macular hyperpigmentation. C. optic disk bulging. D. pupillary constriction.
C
Systemic corticosteroid therapy would be most appropriate in treating: A. tension-type headache. B. migraines occurring on a weekly basis. C. intractable or severe migraines and cluster headaches. D. migraines occurring during pregnancy.
C
When evaluating the person who has bacterial meningi- tis, the NP expects to find cerebrospinal fluid (CSF) results of: A. low protein. B. predominance of lymphocytes. C. glucose at about 30% of serum levels. D. low opening pressure.
C
With appropriately prescribed headache prophylactic therapy, the patient should be informed to expect: A. virtual resolution of headaches. B. no fewer but less severe headaches. C. approximately 50% reduction in the number of headaches. D. that lifelong therapy is advised.
C
You see a 48-year-old patient who started taking varenicline (Chantix) 4 weeks ago to aid in smoking cessation. Which of the following is the most important question to ask during today's visit? A. "How many cigarettes a day are you currently smoking?" B. "On a scale of 0 to 10, how strong is your desire to smoke?" C. "Have you noticed any changes in your mood?" D. "Are you having any trouble sleeping?"`
C Specifically, depressed mood, agitation, changes in behavior, suicidal ideation, and suicide have been reported in patients attempting to quit smoking while using varenicline. Patients should tell their healthcare provider about any history of psychiatric illness before starting this medication; clinicians should also ask about mental health history before starting this medication. Close monitoring for changes in mood and behavior should follow.
minimum Dx eval in CAP
CBC w/ WBC diff and CXR Additional testing based on pt presentation and comorbidity
sepsis test
CBC with diff blood culture UA and culture and sensitivity then, if clinical presentation shows need:: LP for CSF CXR Stool culture, fecal WBC count if diarrhea
HRxSV=
CO
implant but with irreg bleed?
COCx3mo OR NSAIDx2wks (ex: 550mg Aleve BID)
Acute cerebral hemorrhage is best identified with which technique?
CT scan
osteoporosis treatment
Calcium, Vit D, weight bearing exercise, estrogen & Bisphosphonates
subconjunctival hemorrhage
Can be caused by vomiting, trauma, pregnancy, sneezing, excessive meds (vasoconstrictors, pain meds) can all cause. benign blood in the white part of the eye
bullous impetigo
Caused by toxin-producing strain of S. aureus, begins as red macules that progress to bullous (fluid-filled) eruptions on an erythematous base; after rupture, a clear, thin, varnish-like coating forms over denuded area; can be mistaken for cigarette burns often requires systemic antimicrobial
epididymoorchitis <35yo tx
Ceftriaxone IM and doxy PO scrotal elevation
spurling test
Cervical Strain Test Positive test: positive if pain radiates into ipsilateral arm - tests radiculopathy
ask about cardiac disease sx
Chest pain--MI Low cardiac output- Dyspnea, HF sx, syncope
Nongonococcal urethritis and cervicitis cause
Chlamydia Trachomatis ureaplasma urealyticum mycoplasma genitalium
10d old with chemosis
Chlamydial conjunctivits sx 5-14 day post exposure need chlam screen in 3rd trimester
Bile acid resins example
Cholestyramine
Tx mild to mod alzheimer
Cholinesterase inhibitor clear though minor and time limited benefits by increasing availability of acetylcholine
sequelae Hep C
Chronic Hep C hepatocellular carcinoma hep failure
febuxostat
Chronic gout drug
Acute Bacterial Prostatitis (uncomplicated with no risk for STI) tx
Ciprofloxacin
loratadine
Claritin
Bacterial meningitis
Classic Triad: fever, HA, nuchal ridgidity CSF findings: ■ Low glucose, PMN predominance Kernig and Brudzinski signs indicate A 25-year-old female presents to her primary care provider reporting fever, headache, nuchal rigidity, and decreased consciousness. She was previously treated for sinusitis. Which of the following is the most likely diagnosis? An acute inflammation of the meningeal tissues surrounding the brain and the spinal cord; specifically, the arachnoid mater and the CSF; diagnosed by increased CSF presssure, increased WBCs, increased proteins, and decreased glucose
second degree burn treatment
Cool, wrap sterile gauze loosely around burn, watch for infection, use sunscreen on area for a year
renal function check, which and how often
Creat, GFR and microalbumin yearly
CAGE
Cutdown, Annoyed, Guilty, Eye-opener; tests for lifetime alcohold abuse and/or dependence but does not distinguish past problems drinking from active present drinking
Which of the following is true about the MMR vaccine? A. It contains inactivated virus. B. Its use is contraindicated in patients with a history of egg allergy. C. Revaccination of an immune person is associated with risk of significant systemic allergic reaction. D. Two doses at least 1 month apart are recommended for young adults who have not been previously immunized.
D
Usual treatment for an adult with acute hepatitis A includes: A. interferon-alfa therapy. B. high-dose ribavirin. C. parenteral acyclovir. D. supportive care.
D bad with coinfection of A and/or C can cause bad liver prob
treatable causes of urinary incontinence
DIAPPERS
heberden's nodes vs Bouchards nodes
DIP joints, OA PIP joint, RA and OA
osteoporosis scan
DXA
Delirium vs dementia onset
Del: abrupt, hours to days, rapid progress Dem: insidious onset, gradual change
Delirium vs dementia duration
Del: hours to days Dem: months to yrs
Delirium vs dementia memory
Del: impair but variable recall Dem: memory loss especially recent events
Delirium vs dementia speech
Del: incoherent confused Dem: word searching, mute later
Delirium vs dementia etiology
Del: precipitated by acute underlying cause like illness Dem: variety of causes
Delirium vs dementia defined
Del: sudden state of rapid changes in brain reflected in confusion, changes in cognition, activity, and LOC Dem: Slowly developing impairment of intellectual or cognitive function that is progresive and interferes with normal functioning
Delirium vs dementia sleep disturb
Del: sundowning Dem: sometimes day night reversible, yes but less definable
Delirium vs dementia reversible
Del: usually when underlying illness resolve Dem: no
Delirium vs dementia psychomotor
Del: yes, hyperkinetic, hypoactive Dem: not until later in Dz
Delirium vs dementia perceptual disturbances
Del: yes, incl hallucinations Dem: not until later
blueberry muffin rash
Description of rash characteristic of congenital rubella.
health belief model
Developed in 1974, one of the oldest social cognition models. Whether a person will choose to engage in healthy behaviors in order to reduce or prevent chance of disease and death. Happens when they think something bad's gonna happen to them if they don't stop.
BPH symptoms
Diminished size and force of urinary stream
1d old with flat facial profile, hypotonia, hyperflexible joints, palmar crease on both hands, brushfield spots
Downs syndrome Trisomy 21
Delirium etiology DELIRIUMS
Drugs-anticholinergics, antipsych, opioids, benzo, etoh etc Emotional Low P02 Infxn Retention of urine, feces Ictal Undernutrition metabolic subdural hematuria
anticholinergic effects
Dry as a bone red as a beet mad as a hatter hot as a hare cant see cant pee cant spit cant shit
acute uncomplicated UTI in nonpregnant women pathogen
E.Coli Klebsiella S.Saprophyticus concern about FQ resistance
question stem: most appropriate
EBP guides the choice of dx, intervention etc
prehns sign
ELEVATION GIVES RELIEF OF TESTICLES
emergency contraceptive
ELLA more effective between days 3-5 Need Rx stop ovum release could stop egg from being implanted better for obesity Plan B OTC delays or inhibits ovulation
Thiazolidinedione risk
Edema (esp when used with insulin or SU) can exacerbate HF (avoid) long term maybe bladder CA risk
Least drug drug interaction potential SSRI
Escitalopram (lexapro)
Drug induced macrocytosis usually without anemia common etiologies
Etiology: Carbamazepine, AZT, Valproic Acid, Phenytoin, alcohol reversable when stop med but not always possible
Gold 3 severe COPD
FEV1/FVC 30-50% predicted
Gold 2 very severe COPD
FEV1/FVC <30% predicted
whats on the test
FNP=largely outpatient primary care with some urgent care. NO ED or inpatient or home or long term care. Will have anatomy, physiology, patho, pharm. Mech of disease, how drug and other tx modify disease. Health promotion and disease prevention. obtaining health hx. interview tech and analyzation. eval s/sx, PE with synth findings. know normal and abnormal. Lab and dx testing- ordering and performing to support and dx. never do a test that doesnt fit. EBP- plan of care based on, guidelines. Assume resources are available to be cost effective EBP. Plan of care and follow up Legal and ethical- malpractice, confident, patient advocacy and competency (some more than others cultural comp, principles of epi healthcare econ and mgmt
colorectal screen
FOBT >50 annual Sigmoidoscopy at 50 every 5 yrs (colon if pos) Colonoscopy every 10 yrs after 50
Fiorecet
Fioricet is a combination medication consisting of caffeine, butalbital, and acetaminophen. Caffeine enhances the analgesic properties of acetaminophen, and butalbital's barbiturate action enhances select neurotransmitter action, helping to relieve migraine and tension-type headache pain. watch for dependency and rebound
syphilitic chancre
Firm *painless ulcer* that develops *internally* and often is *undetected*
suppurative conjunctivitis first line
First Line: Fluoroquinolones: gatifloxacin, levofloxacin, moxifloxaci
pathologic split S2 significance where heard best
Fixed Split=no change on inspiration Paradoxical split: narrows/closes on inspitation heard best at pulmonic Fixed=uncorrected septal defect Paradoxical=delay aortic closure (ex:LBBB) tx underlying condition
vesicle
Fluid-filled, <1 cm ex: Varicella
bullae
Fluid-filled, ≥1 cm ex: Blister with second-degree burn
high potency topical corticosteroids
Fluocinolone acetonide 0.2% (Synalar-HP) Desoximetasone 0.25% (Topicort) Fluocinonide 0.05% (Lidex)
pyelonephritis treatment
Fluroquinolone (Cipro or Levofloxacin), or Ceftriaxon
Migraine with aura
Focal dysfunction of cerebral cortex or brain stem cause 1+ aura over 4 min or 2+ in succession Sx- dread, anx, fatigue, nerve, excite, GI, visual, olfactory No aura should last 1+ hr Fam hx: 70-90%
newborn formula, BF amt and freq
Formula: 1.5-3 oz every 2-3 hrs BF: 1.5-3 hrs, no more than 4 min 8-12 feedings/day
2 mo formula, BF amt and freq
Formula: 4-5 oz every 2-4 hrs BF: min 7-9 feedings/day
4 mo formula, BF amt and freq
Formula: 4-6 oz every 3-4 hrs BF: min 6-8 feedings/day
6 mo formula, BF amt and freq
Formula: 6-8 oz every 4-5 hrs BF: min 4-6 feedings/day
1st prenatal visit screen
GC/CT Rubella, varicella, robeola if unknown RPR, HIV, HB, HCV CBC, type and AB DV, depression TB Genetic US UA and C&S (tx asymptomatic bacteriuria)
cholelithiasis
Gallstones suspect=hepatic enzyme analysis and RUQ US
NSAID adverse effects
Gastrointestinal distress: inhibit protective COX-1 production of PGI2 & PGE2, also local irritation causing ulceration
3 G's herbal products often taken by elderly
Ginkgo Biloba Ginseng Garlic potential antiplatelet and problematic with Rx antiplatelet meds, solo or in combo
Stage A HF tx
Goal: heart health lifestyle prevent coronary Dz prevent LV structural abnorm ACE/ARB for vascular Dz or DM statins if appropriate
common bacteria in COPD flare cause
H.influenzae Haemophilus parainfluenzae Strep Pneumoniae
Acute disease marker Hep A
HAV IgM (M=miserable) Elevated hep enz 10x+
Acute disease marker Hep B
HBV core IGM ab= earliest marker to become pos post HBV exposure HBsAg=Always Growing surrogate marker for HBV HBeAg=Notes a time when HBV is Extra contagious, Extra growing Elevated hep enz 10x+
Hep B Hx IZ marker
HBsAb and norm enz
thiazide diuretics example
HCTZ chlorthalidone
Stage C HF example and definition
HFpEF and HFrEF
genital herpes cause
HHV-2
roseola
HHV-6 discrete rosy pink macular rash lasts hours-3d but FIRST 3-7d fever often high mostly, <2yo sometimes febrile Sz supportive tx
Hib vaccine
HIB: H Flu type B (meningitis, PNA, epiglottitis, cellulitis). To decrease invasive dz in children. Decreases nasal carriage if they dont have the vax and they are adolescent, often you can just skip it
Genital warts cause
HPV 6 and 11 most common others associated with GU malignancy common to have multiple
BP=
HRxSVxPR
HA and presenting sx of serious illness
Headache rarely can be the presenting symptom of a serious illness.
3 top killers in adults in US
Heart Disease, cancer, Chronic lower respiratory diseases
Post exposure prophylaxis available? Hep A, B, C
Hep A: Yes and immunize close contacts Hep B: Yes and immunize close contacts Hep C: No
IZ to avoid with hx of anaphylactic reaction to bakers yeast
Hep B
vaccines by 6 months
Hep B at birth RV DTAP Hib PCV IPV IIV (flu shot)
saw palmetto
Herbals: Prostate mostly benign
prepatellar bursitis
Housemaids knee can be cause by repeated trauma or pressure from extensive kneeling. Swelling on anterior knee between patella and skin. A tender, mass indicates swelling; in some cases, infection spreads to surrounding soft tissue. Overlying skin may be red, shiny, atrophic, or coarse and thickened.
most consistent findings with malignant thyroid nodule
Hx of head and neck irradiation >4cm Firm nontender on palpation nonmobile persistent nontender lymphadenopathy dysphonia hemptysis
Acute otitis media Hx, findings, Tx
Hx: -Sensation of ear fullness, pressure and otalgia. -Conductive hearing loss. -Fever common Findings: -TM redness, bulging -Cone of light and bony landmarks absent -TM mobility with pneumatic otoscopy absent -Otorrhea possible with TM rupture Tx: -Analgesia, antimicrobial therapy typically given. However, high rate of spontaneous resolution without antimicrobial treatment
Otitis media with effusion hx, findings and tx
Hx: sensation of ear full or pressure itch otalgia conductive hearing loss no fever or otorrhea Findings: -Air fluid level visible, often with air bubbles -Opaque yellow or blue color -Cone of light and bony landmarks diminished or absent -TM mobility with pneumatic otoscopy limited Tx: underlying cause like allergic rhinitis. Usually resolves 1-3 wks without intervention
low potency topical corticosteroids
Hydrocortisone (0.5%, 1%, 2.5%) Fluocinolone acetonide 0.01% (Synalar) Triamcinolone acetonide 0.025% (Aristocort) Fluocinolone acetonide 0.025% (Synalar) Hydrocortisone butyrate 0.1% Hydrocortisone valerate 0.2% (Westcort) Triamcinolone acetonide 0.1%
A 68-year-old man presents with new onset of headaches. He describes the pain as bilateral frontal to occipital and most severe when he arises in the morn- ing and when coughing. He feels much better by mid- afternoon. The history is most consistent with headache caused by:
ICP
COPD anti inflammatory to minimize exacerbation
ICS
most common type anemia in peds
IDA microcytic hypochromic elevated RDW
microcytic hypochromic anemia with elevated RDW what anemia and what is next step?
IDA next step: Ferritin for estimate of iron stores
most common anemia in childhood, preggo, reproductive years, elderly
IDAx3 elderly: ACD so we will see a lot of IDA questions
IZ to avoid with hx of anaphylactic reaction to neomycin
IPV, MMR, varicella
IZ to avoid with hx of anaphylactic reaction to Streptomycin, polymyxin B, neomycin
IPV, smallpox
kawasaki disease tx
IV immunoglobulin and PO aspirin in acute to reduce coronary aneurysm need consult/hosp to monitor
BEERS criteria
Identifies High Risk Meds to Generate Wide List of Meds That Should be Avoided
verruca vulgaris tx
Imiquimod cream
Injectable migraine relief
Imitrex (sumatriptan and dihydroergotamine (DHE) rapid onset (15-30 min) good if GI upset assoc sx Sumatriptan is self injected DHE is IV along with hydration expensive some of the ergot and triptan are available as nasal spray and with similar tolerance can use analgesic or antiemetic for pain control or GI upset as well
PPD needs to be above 10mm
Immigration from high-prevalence countries in last 5 years, IV drug use, employment or residence in high-risk congregate settings, employment in mycobacteriology lab, high- risk clinical conditions, age < 4 years, childhood (including adolescent) exposure to adults in high-risk categories
presbyopia
Impairment of vision due to old age
specificity
In medical screening, what is the term for the proportion of truly disease-free individuals who are correctly identified as not having the disease?
FDA approved antiviral drugs for flu
In the United States, four antiviral drugs are approved by the Food and Drug Administration (FDA) for use against influenza: amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), and oseltamivir (Tamiflu).
moro reflex
Infant startle response to sudden, intense noise or movement. When startled the newborn arches its back, throws back its head, and flings out its arms and legs. Usually disappears after four months.
diverticulitis
Infected or inflamed pouch (diverticulum) in the colon. Common in older persons; Low-fiber diet and constipation are risk factors.
cellulitis
Inflammation of subcutaneous, loose connective tissue; skin infection likely cause by Strep Pyo, Staph Aur, MRSA require systemic antimicrobial
meningococcal meningitis
Inflammation of the meningeal coverings of the brain and spinal cord that can be highly contagious; isolate pt for 24 h after starting antibiotics
flunisolide
Inhaled corticosteroid
Which of the following statements best describes zanamivir (Relenza) or oseltamivir (Tamiflu) use in the care of patients with or at risk for influenza?
Initiation of therapy early in acute influenza illness can help minimize the severity of disease when the illness is caused by a nonresistant viral strain.
pyloric stenosis vs intussusception sudden onset, colicky, severe intermittent abd pain
Intussusception
atrovent
Ipratropium bromide
markel sign
Jarring the heel; pain = appendicitis
osteoarthritis
Joint pain and stiffness that worsen over the course of the day and are relieved by rest.
Anterior Uveitis (Iritis) clinical presentation
Keratic precipitates in cornea Posterior synechiae in iris pupil constricted, nonreactive, irreg shape perilimbal injection (ciliary flush)
most common sites of disk bulge
L4-L5 L5-S1
COPD protracted duration bronchodilation Rx
LABA (salmeterol) not PRN
LAIV is approved for___
LAIV is approved for use in healthy people ages 2 to 49 years old It is not for patients with a health condition that places them at high risk for complications from influenza, including chronic heart disease, chronic lung dis- ease such as asthma or reactive airways disease, diabetes or kidney failure, and immunosuppression; children or adolescents receiving long-term high-dose aspirin therapy; people with a history of Guillain-Barré syndrome; pregnant women; and people with a history of allergy to any of the components of LAIV. Adverse effects of LAIV include nasal irritation and discharge, muscle aches, sore throat, and fever.
COPD protracted duration bronchodilation that minimizes risk of COPD exacerbation
LAMA tiotroprium bromide not PRN
mod intensity statin example
LDL dec 1/3+ ator rosu also simvastatin pravastatin lovastatin
low intensity statin example
LDL dec 1/4+ prava lova
HMG-CoA reductase inhibitor effect
LDL dec 18-55% HDL inc 5-15% TG dec 7-30%
high intensity statin ex
LDL reduce >50% atorvastatin rosuvastatin long half life more bioavailability
Statin algorithm if no ASCVD
LDL>190? high intensity if no, DM? mod or if ASCVD risk >7.5, high
Next step if positive for infxn Hep A
LFT notify pub health Tx: supportive care liver transplant an option in failure sometimes but rare
Next step if positive for infxn Hep B
LFT screen for coinfection HepA,C,HIV,STI Immunize HAV is req refer to expert consult
Next step if positive for infxn Hep C
LFT and coinfxn test and refer
presentation of inhalation anthrax and tx
LGF, nonproductive cough, nonspecific presentation tx- fluoroquinolone and consult
menopause sx
LH and FSH inc more frequent hot flashes
severe dehydration tx peds
LR preferred over normal saline bolus 20mL/kg until improvement (perfusion, LOC) then 100mL/kg over 4 hrs
ACL test PE
Lachman's test
purpura
Lesions caused by red blood cells leaving circulation and becoming trapped in skin Petechiae, ecchymosis
epididymoorchitis >35yo or having anal intercourse tx
Levofloxacin
APRN consensus model LACE
Licensure- Scope determined at state level Accreditation Certification- formal recog of knowledge skills and exp identified by profession Education- formal prep for APRNs
1-2 mo motor, reflex
Lifts head Hold head erect Follows objects through visual field Moro reflex fading
brown recluse spider bite
Lives in dark, undisturbed areas, violin mark on back, Mild stinging, fatty areas become necrotic in hours, "blue-gray" bullae, can cause hemolytic anemia, DIC, death. Tx: Ice, elevation, abx, ASA
vas deferens
Long, narrow tube carrying sperm from epididymis to ejaculatory duct
Heart Murmur grade 4
Loud with thrill
most common reason for low back pain
Lumbar sacral strain
Low back pain DD
Lumbar sacral strain Lumbar radiculopathy
less likely but still poss bacterial cause of acute bronchitis. ex:
M&C pneumo B. Pertussis( keep in back of mind if other cases related etc) bacteria is 10% of all consider macrolide or tetracycline
most common pneumonia is children and young adults
M. Pneumo
normocytic normochromic anemia
MCV=80-96 NL RDW NL MCHC most common etiology=acute blood loss or ACD
IZ to avoid with hx of anaphylactic reaction to gelatin
MMR
live virus
MMR, varicella, flumist, zoster rotavirus in young infants, contra indicated if have SCID
HA MRI vs CT
MRI expensive 4x more CT without contrast is cheapest for acute bleed CT with contrast for Tumor/abscess MRI- better for soft tissue so tumor, lesions
MS diagnosis
MRI scans, CSF analysis
MS treatment
MS treatment generally falls into three categories: therapy for relapses, long-term disease-modifying medications, and symptomatic management. interferon beta-1b to attenuate disease progression
order heart valves close
MTAP
nitrofurantoin
Macrobid Used for recurrent UTI change dose for renal impair
effective ABX for M&C.Pneumoniae non resistant
Macrolide, Fluoro, doxy bad with dorm, prison, etc
effective ABX for S.Pneumoniae non resistant
Macrolides (mycin) Amox
leading cancer deaths
Male: lung, prostate Female: Lung, Breast
leading sites for new cancer cases
Male: prostate and lung Female Breast and lung
breast cancer screen
Mammography q2Y starting at age 50 (USPSTF) or 40 (ACOG)
S4 Heart sound significance where heard best
Marker of poor diastolic function found in poor controlled HTN or recurrent MI Hears late diastole sound like hooked on to S1 AKA presystolic soft low pitch (higher than S3)
measles and mumps sx
Measles can cause severe illness with serious sequelae, including encephalitis and pneumonia; sequelae of mumps include orchitis and possible decreased male fertility.
mcmurray test
Meniscal Tear With patient supine and knee internally and externally rotated during range of motion
Potential Lifestyle, Health Status or Medication Triggers Influencing the Onset or Severity of Migraine Symptoms:
Menses, ovulation, or pregnancy Birth control/hormone replacement (progesterone) therapy Illness of virtually any kind, whether acute or chronic Intense or strenuous activity/exercise Sleeping too much/too little/jet lag Fasting/missing meals Bright or flickering lights Excessive or repetitive noises Odors/fragrances/tobacco smoke Weather/seasonal changes High altitudes Medications Stress/stress letdown
lithium
Mood Stabilizer Bipolar Disorder
Fragile X syndrome
Most common form of mental retardation, a mutation of the FMR-1 gene Distinctive facial characteristics include long face and large ears. Disorders can vary from mild to severe.
Test of L4 nerve root
Motor--Foot dorsiflexion Reflex--knee jerk Sensory--medial calf
test of S1 nerve root
Motor--Foot eversion Reflex--ankle jerk Sensory--lateral foot
Test of L5 nerve root
Motor--Great toe dorsiflexion Reflex--none Sensory--Medial foot
newborn motor, reflex
Moves all extremities Reacts to sound by blinking, turning Well-developed sense of smell Preference for higher-pitched voices Reflexes Tonic neck Palmar grasp Babinski response Rooting awake and sleep Suck
Gonococcal urethritis and cervicitis cause
N.gonorrhoeae (G-)
TSH
NL 0.5-1.5 mean is 1.2 this is the goal eval of anterior pit to detect amount of circulating free thyroxine it is ok to do the TSH alone, hmm
NL optic disk
NL because of balance between intraocular pressure and intracranial pressure
reticulocyte %
NL response to anemia is inc RTC healthy=1-2% NL response to anemia is>2% (reticulocytosis)
Peripheral Neuropathy Tx
NSAID for pain antiSz or AntiD, lidocaine patch, opioids TENS
HA analgesics
NSAID, tylenol etc best taken at onset
myopia
Nearsightedness
mnemonic for recall cell lines in order of reporting for WBC
Neutrophil- get activiated in presence of bacterial infxn Debris: like a splinter, or a suture % of differential= % of WBC
mild-mod dehydration tx peds
ORT with Oral rehydration solution (pedialite) 50-100mL/kg over 3-4 h frequent small volumes
Brushfield spots
On the iris. Down Syndrome.
HIV and pneumo vax
Once the diagnosis of HIV infection is made, the patient should receive both PCV13 and PPSV23 vaccines as soon as possible; PCV13 is given first followed by PPSV23 8 weeks later. A second dose of PPSV23 should be administered at least 5 years after the initial dose, and a third dose should be administered at age 65 years if the person was younger than age 65 years at the time of HIV diagnosis.
insulin onset of action, peak, duration of action short acting/rapid lispro/novolog (aspart)
Onset- 15 min Peak- 1hr Duration: 4hr
insulin onset of action, peak, duration of action intermediate NPH/novolin N/Humulin N
Onset: 1-2h Peak: 6-14h Duration: 16-24h
insulin onset of action, peak, duration of action short acting/regular Humulin R/Novolin R
Onset: 30 min Peak: 2-3 h Duration: 3-6h
insulin onset of action, peak, duration of action Long acting/Basal Detemit/glargine
Onset:1-2h Peak: none Duration: 24h
trich tx
Oral metronidazole 1x dont use ETOH 24-72 hrs
vertebral compression fracture
Osteoporosis (type I: postmenopausal women; type II: elderly men or women)
1-2d mild fever in 6 mo old most likely to occur after what vax..
PCV13 (pneumo)
COPD add on for exacerbation
PDE-4 inhibitor roflumilast not great but used bad AE
venous insufficiency Dx
PE of appearance of leg veins Duplex US maybe
erosive gastritis tx
PPI
tx gerd
PPI for presumptive dx
first line for H Pylori
PPI, clarithro and Amox for NON Penecillin allergy metro if allergy
PSA testing
PSA testing is a dialogue
Lumbar sacral strain on PE
Paraspinal muscle tender and spasm LS curve straightening Dec LS flexion NORMAL NEURO EXAM
erosion
Partial focal loss of epidermis; heals without scarring ex: Area exposed after bullous lesion opens
exudative pharyngitis first line
Penicillin Alt: erythromycin
Macrocytic, normochromic, with elevated RDW DX and next step
Pernicious anemia (most common), dietary induced (B12, folate) (uncommon) MCHC is NL because Iron has nothing to do with it Next step: test B12 and folate Pernicious is generally a much lower H&H
postherpetic neuralgia
Postherpetic neuralgia is a nerve pain due to damage caused by the varicella zoster virus.
sepsis
Presence of pathological microorganisms or their toxins in the blood or tissue results in systemic inflammatory response
giant cell arteritis presentation
Present with new headache (unilateral or bilateral); scalp pain and temporal tenderness; and jaw claudication.
pityriasis rosea
Presents with a herald patch, Christmas-tree pattern. cause unknown, self limiting illness lasting 4 weeks to 8 weeks and asymptomatic. Pt c/o oval lesions with fine scales that follow skin lines(leavage lines) of the trunk or a "christmas tree" pattern. "Herald Patch"first lesion to appear and largest in size, appears 2 weeks before full breakout.
pyloric stenosis vs intussusception
Pyloric: upper GI, thickening of pyloric valve so stomach cant empty Intuss: lower GI, telescoping of small intestine into the large intestine that causes an obstruction
RDW
RBC distribution width index of variation in RBC size NL=11.5-15% ABN: >15% indicating that new cells differ in size early lab indicator of an evolving microcytic or macrocytic anemia
As MCV decreases As MCV increases
RDW increases RDW increases high RDW =new cells differ in size from old cells
meniscal tear tx
RICE initially maybe aspiration after 2-4 wks with no improvement Arthroscopy for debridement and repair at 4-6 wks no improvement or earlier if joint effusion or locking
what do you need to practice
RN license, national NP cert, NP license, state rx authority, fed DEA authority, cred with agency and insurance companies
papule
Raised lesion, <1 cm, may be same or different color than the surrounding skin ex: raised nevus
nodule
Raised lesion, ≥1 cm, usually mobile ex:epidermal cyst
4 months remember
Reaches 4 toy smiles 4 fun rolls from tummy to back
3-5mo motor, reflex
Reaches for objects Brings objects to mouth Raspberry sound Sits with support Rolls back to side
dx of AOM in kids
Red eardrum +pain mod-severe bulging of TM or new onset otorrhea not related to otitis externa with otalgia mild bulge TM and recent (<48hrs) onset ear pain OR intense TM erythema with otaligia
most common pathogen in acute bronchitis
Respiratory Virus 90%
Secondary hyperparathyroidism etiology
Result of another condition that lowers Ca and therefore causes the Parathyroid to overproduce PTH Etiology: Severe Ca or Vit D deficiency, CKD
DMARD therapy
Rheumatoid Arthritis Tx *Mildly active RA* Anti-inflammatory + NSAID = rapid relief (Add sulfasalazine (SSZ)
ABX dont use with COC
Rifampin continue use with back up and use back up 7 days after
OD OS OU
Right eye, left eye, both eyes
ceftriaxone
Rocephin Third−generation cephalosporin: active against resistant bacteria including gonococci, H influenzae, and other gram−negative organisms. Crosses the blood−brain barrier
Rubella
Rubella typically causes a relatively mild, 3- to 5-day illness with little risk of complication to the person infected. When rubella is contracted during pregnancy, however, the effects on the fetus can be devastating.
scarlet fever
S. pyogenes pharyngitis with a skin rash- sandpaper like rash erupts on day 2 and often peels a few days later
Pt has CAP, prev healthy, no recent ABX. Likely pathogen and recc Tx
S.Pneumo Atypicals M&C RSV, influenza, adeno, para Macrolide like azithro etc or Doxy
Pt has CAP and comorbidities or immuno or malignancy, or recent ABX Likely pathogen and tx:
S.Pneumo H. influ atypicals RSV etc Fluoros or Macrolide+beta lactam
most common cause of fatal CAP
S.Pneumoniae
CAP likely causative pathogens requiring inpatient tx
S.Pneumoniae M.Pneumonia C.Pneumonia Legionella H.Influenzae RSV, adenovirus, parainfluenza
CAP likely causative pathogens suitable for outpatient tx
S.Pneumoniae M.Pneumonia C.Pneumonia RSV adenovirus, parainfluenza
causative pathogens for ABRS, AOM, and CAP
S.Pneumoniae (#1) G+ >25% drug resistant H. Influenzae (#1 in kids) G- >30% penicillin resistant M.Catarrhalis (less with CAP) G- >90% penicillin resistant
CHF heart sounds
S1 S2 S3
cranial nerves
S=sensory M=motor B=bot oh oh oh to touch and feel a girls very soft hands Olfactory- smell Optic- Vision Oculomotor- Eyelid and eyeball movement Trochlear- Innervates superior, oblique, turns eye down and lateral Trigeminal- chewing, face, and mouth touch and pain Abducens- turns eye lateral Facial- most facial expressions and secretion of tears, saliva, taste Acoustic- hearing, equilibrium, sensation Glossopharyngeal- taste, senses carotid, BP Vagus- Senses aortic BP, slows HR, stim digestion, taste Spinal Accessory- Control traps and sternoclei, swallow Hypoglossal- control tongue move
acute reliever med for intervention in acute bronchospasm
SABA >2d/wk=need for better control also for exercise induced 15-30 min prior
asthma tx
SABA as acute reliever persistent=inhaled corticosteroid preferred step up if not well controlled written action plan education
COPD relief of bronchospasm Rx
SABA or SAMA (ipratroprium bromide) usually PRN
sex AE with SSNI, SDRI
SNRI-40% SDRI-20% take a 1 day/wk drug holiday if want sex
Heart failure symptoms
SOB, cough, WOB increases,
1st line tx for Anxiety
SSRI
Sulfonylurea (SU) when to give
SU pushes out insulin all the time so can give nocturnal fasting and 4-6h after meal
psoriatic arthritis
Sausage-finger appearance
oligomennorhea
Scanty menstrual flow
Acute bacterial rhinosinusitis
Secondary bacterial infection of paranasal sinuses usually following URI; relatively uncommon
pyloric stenosis tx
Sg
Primary hyperparathyroid intervention
Sg to remove problematic gland (95% cure) Cinacalcet- Tx if pt also has CKD or PTH Cancer consider HRT or something to prevent bone loss
IBS vs IBD
Similar to IBD, but much more mild: will contain some irregular diarrhoea bouts and bowel disturbance, but no 'red flag' symptoms, like blood discharge (UC), vomiting (CD) or weight loss.
During an outbreak of meningococcal meningitis, all of the following can be used as chemoprophylaxis
Single dose Ceftriaxone Multiple doses Rifampin Single dose MCV4
6-8mo motor, reflex
Sits briefly without support Scoops small object with rake grip; some thumb use Hand-to-hand transfer
Major depressive episode Dx Need 5+ SIGECAPS
Sleep Interest (loss of) Guilt Energy Concentration Appetite (weight change inc or dec) Psychomotor Suicide
molluscum contagiosum
Smooth wax like round (dome shaped) papules 5 mm size. Central umbilication with white plug
Potential Dietary Triggers Influencing the Onset or Severity of Migraine Symptoms:
Sour cream Ripened cheeses (cheddar, Stilton, Brie, Camembert) Sausage, bologna, salami, pepperoni, summer sausage, hot dogs Pizza Chicken liver, pâté Herring (pickled or dried) Any pickled, fermented, or marinated food Monosodium glutamate (MSG) (soy sauce, meat tenderizers, seasoned salt) Freshly baked yeast products, sourdough bread Chocolate Nuts or nut butters Broad beans, lima beans, fava beans, snow peas Onions Figs, raisins, papayas, avocados, red plums Citrus fruits Bananas Caffeinated beverages (tea, coffee, cola) Alcoholic beverages (wine, beer, whiskey) Aspartame/phenylalanine-containing foods or beverages
Aldosterone antagonist example
Spirnoloactone
9-11 mo motor, reflex
Stands alone Imitates peek-a-boo Picks up small object with thumb and index finger Cruises
erysipelas
Streptococcus pyogenes Symptoms include edema, redness, fever, pain, lymphadenopathy, can progress to septicemia and local necrosis of skin need systemic antimicrobial
5 A's
Successful intervention based upon willingness to quit Ask (ask and document every visit) Advise (urge to quit) Assess (are they willing to) Assist (counseling and pharmacotherapy) Arrange (follow up contact preferably within a week)
systolic vs diastolic cardiac murmurs outlook and pneumonic
Syst:benign or pathologic Diast: always pathologic Systolic: MRPASS Mitral regurge, physiologic, aortic stenosis, systolic MR. Pass wins MVP Mitral Valve Prolaps Diastolic: MSARD Mitral stenosis, Aortic regurge, Diastolic
Red flags of HA SNOOP
Systemic sx or secondary HA risk factors Neurologic Sx- newly acq finding, confuse, neck stiff, papilledema, CN dysfunction Onset- thunderclap HA- Subarachnoid hem, onset with exertion, sex, cough, sneeze could be ICP Onset (age): over 50 and under 5 Previous Hx- first HA is >30, or diff pattern or features
rifampin
TB Antimicrobial: inhibitor of DNA−dependent RNA polymerase used in drug regimens for tuberculosis and the meningococcal carrier state. Tox: hepatic dysfunction, induction of liver drug−metabolizing enzymes (drug interactions), flu−like syndrome with intermittent dosing
finkelstein test
TESTING: De Quervain's syndrome, tenosynovitis of the extensor pollicis brevis and abductor pollicis longus pt asked to make a tucked-thumb fist -- EBP or EPL pain may indicate tenosynovitis
Fish oil effect at 4g
TG dec 20-30%
eval of thyroid nodule
TSH, US to determine location and characteristics TSH low? Thyroid scan- Hot? ablation or Sg not hot? biopsy TSH ok? Biopsy
straight leg raising test
Tests for *Sciatica Positive: patient complains of pain along sciatic nerve, indicates nerve root irritation from intervertebral disk prolapse and herniation at level L4-5 or L5-S1.
Tetanus is caused by
Tetanus infection is caused by Clostridium tetani, an anaerobic, gram-positive, spore-forming rod. found in soil, especially manure. enters through wound
MMR and pregnant women
The MMR vaccine is safe to use during lactation, but its use during pregnancy is discouraged because of the theoretical but unproven risk of congenital rubella syndrome from the live virus contained in the vaccine.
where does the aura in migraines come from and about migraine with aura
The aura is a recurrent neurological symptom that arises from the cerebral cortex or brainstem. 20% of migraine sufferers have aura Typically, the aura develops over 5 to 20 minutes, lasts less than 1 hour, and is accompanied or followed by migraine. Patients who have migraines with aura do not have more severe headaches than patients with-out aura, but the former patients are more likely to be offered a fuller range of therapies. Patients without aura may be misdiagnosed as having tension-type headaches and are often not offered headache therapies specifically suited for migraines, such as the triptans.
sensitivity
The number of true positives divided by the number of patients with the disease is _____.
angioedema
The nurse observes that after administration of a drug that the patient has developed swollen eyelids, lips, and mouth. what kind of drug reaction is this?
NSAID for migraines
These products inhibit prostaglandin and leukotriene synthesis and are most helpful when used at the first sign of headache, when GI upset is not a significant issue. Use rapid onset like ibuprofen in high doses with booster doses
black normal HTN 1st line
Thiazide and CCB alone or in combo
tx for cluster HA
Treatment includes reduction of triggers, such as tobacco and alcohol use, and initiation of prophylactic therapy and appropriate abortive therapy (triptans, high-dose NSAIDs, and high-flow oxygen).
Syphilis cause
Treponema pallidum
trich cause
Trichomonas vaginalis
cardio and neurotoxic mental health med
Tricyclic antidepressant nortripyline
meds with significant systemic anticholinergic effect
Tricyclics overactive bladder meds (ditropan) 1st gen antihistamines select antipsychotics
Migraine specific meds
Triptans Ergot derivatives take an onset
Edwards Syndrome
Trisomy 18 Infant with microcephaly, rocker-bottom feet, clenched hands, and structural heart defect. most die
ABRS DX
URI s/sx either persistent and not improving >10D, severe >3-4 days, or worsening or double sickening >3-4D
echinacea
Uses: Prevention and treatment of upper respiratory tract infection, immune function stimulation mostly benign
Secondary hyperparathyroidism intervention
Vit D analogues and calcimimetics Sg only if med fails Ensure Ca and Vit D intake
Tx to slow decline in alzheimer
Vit E or Selegiline both are antioxidants
leukocytosis
WBC>10000
zollinger-ellison syndrome
What is a beta cell tumor that secretes an excess of gastrin, which causes multiple peptic ulcers in aberrant locations, known as?
psoriasis vulgaris
What is the most common variant of psoriasis? Knees and tips of elbow Auspitz sign when someone scrapes one of the scales and it starts to bleed
question for derm: are there primary lesions only? Primary and secondary?
Where is the oldest lesion and when did it occur? Where is the newest lesion and when did it occur? allows for assessment of evolution
physiologic split S2 significance where heard best
Widening of normal interval b/t aortic and pulmonic caused by delay in pulmonic normal/benign heard best in pulmonic region INc on INspiration
RBC size
Wintrobe's classification of anemia by evaluation of MCV Microcytic: small cell with MCV<80 fL Normocytic 80-96 Macrocytic= MCV>96 key to knowing and interpreting
Generalized Anxiety Disorder Dx Need 3+ WATCHERS
Worry Anxiety Tension in muscles Concentration difficulty Hyperarousal or irritability Energy loss Restlessnes Sleep disturbance
Turner syndrome
XO female noted when girl hits puberty short, notice by 5yo, web neck, broad chest, ansent menses, infertility no ovaries to produce estrogen sometimes noticeable at birth high miscarriage blood testing available
Klinefelter syndrome
XXY only males femenized body type development issues there is blood testing
Knee OA Dx
Xray to distinguish from other types of arthritis imaging shows narrow of joint space, change in bone, spurs
Immunization available? Hep A, B, C
Yes, Yes, No
adverse affects of the 2 main flu antiviral drugs
Zanamivir is inhaled and can cause bronchospasm, especially in patients with asthma or other chronic lung disease. The adverse effects of oseltamivir are largely gastrointestinal; the risk of nausea and vomiting is significantly reduced if the medication is taken with food.
pterygium
a benign growth on the cornea that can become large enough to distort vision
3rd degree burn
a burn involving all layers of the skin; characterized by the destruction of the epidermis and dermis, with damage or destruction of subcutaneous tissue.
1st degree burn
a burn involving only the epidermis; characterised by erythema (redness) and hyperethesia (excessive sensation) tx: cold compress, lotion or ointment, tylenol or ibu
2nd degree burn
a burn involving the epidermis and the dermis; characterised by erythema, hyperesthesia, and visitations (blisters)
Acne Vulgaris
a chronic inflammatory disease characterized by pustular eruptions of the skin caused by sebum around the hair shaft
anaphylaxis
a severe response to an allergen in which the symptoms develop quickly, and without help, the patient can die within a few minutes. acute life threatening systemic reaction, mast cell and basophil release can be variable despite uticaria and respiratory compromise are more common BP drop, not as common but does happen
vitiligo
a skin condition resulting from the destruction of the melanocytes due to unknown causes autoimmune
Thyroid peroxidase antibody (TPO Ab)
a test to help detect autoimmune thyroid disease
6-8 mo remember
able to sit up and can transfer objects hand to hand
systolic murmur, likely pathologic if..
abn hx higher grade 4+ radiation no S1S2 with thrill heave PMI displace inc with intensity with position change
IBS sx
absence rectal bleed, fever, wt loss, elev CRP, ESR broad diff dx
most common cause of adolescent death in US
accidental death
cystic acne tx
accutane
Abortive HA tx
acetaminophen; NSAIDs; and combi- nation products such as butalbital with acetaminophen, and acetaminophen, aspirin, and caffeine.
mild cognitive impairment tx
acetylcholinesterase inhibitor can delay but not prevent progression
what do t4 and t3 do
act as cellular energy release catalysts and influence the function and health of every cell in the body so think about that happens when there is too much or too little with the hormones
sun exposed areas location condition
actinic keratosis
A 44 year old alcoholic male presents with severe epigastric pain that began shortly after a heavy bout of alcoholic intake, and reached maximum intensity over a period of two hours. The pain is constant, radiates straight through to the back and is accompanied by nausea, vomiting and retching. He had a similar episode two years ago, for which he required hospitalization.
acute pancreatitis
epigastric pain that radiates to the back
acute pancreatitis
giant cell arteritis concomitant diseases
acute pancreatitis. psoriatic arthritis. reactive arthritis.
genital herpes tx
acyclovir
Zoster tx
acyclovir early analgesia tx itch systemic and local
varicella treatment
acyclovir early 24-48 hrs and in high risk for underlying problems can help minimize severity avoid aspirin due to Reyes and NSAID due to necrotizing fascitis
ACEI ARB risk
adjust dose in renal insuff do not use for bilateral renal artery stenosis modest hyperkalemia risk ACEI cough- can use ARB alternative ACEI- angioedema (less with ARB) preg cat D
tanner stage 5
adult
MS risk factors
affects 15 to 50 years of age, women more than men, genetic factor, viruses such as epstein-barr, white with European dissent,thyroid disease, DM1, inflammatory bowel disease, high risk areas after puberty.
onset of physiologic jaundice
after 12 hours of life
when notice fragile X syndrome
after beginning of puberty
age test DMII if considerations
age 10 or onset of puberty and every 3 yrs
Macular degeneration
age related mostly thickening sclerotic changes in retinal basement membrane complex painless vision changes central soft yellow deposits often visible
etiology- need for increased illumination
aging
Giant cell arteritis intervention
aim to reduce pain and minimize risk of blind high dose systemic corticosteroid f/u with careful reduce dose and continued for 6 mo-2 yrs Aspirin for stroke risk PPI for GI protection Bisphosphonate for bone protection
booster seat in car
all kids until 4ft9 and 8-12 yo
screening thyroid reccomendations
all over the place >35 every 5 yrs >60 >50
acne tx education
all tx takes 6-8 wks before significant effect topical tx over entire skin region not just spot therapy
second generation antipsychotics
allegra, seroquel etc
allergic rhinitis 1st line tx
allergen avoidance and environmental control
prevent acute gout
allopurinol or febuxostat is 1st line urate lowering therapy cochicine is 1st line too low dose NSAID as well
dermatomal
along a neurocutaneous dermatome ex: herpes zoster
IBS basic
altered GI motility and visceral hyperalgesia microscopic inflammation, altered gut flora
secondary lesions
altered by outside manipulation, treatment, natural course of disease ex: crust because develops when vesicle ruptures
small and pale cells
always go together
which flu drugs are only for influenza A and what are the new reccs for them
amantadine (Symmetrel), rimantadine (Flumadine) high levels of resistance of influenza A viruses to amantadine and similar medications. Because of this significant level of resistance, amantadine and rimantadine are no longer recommended by the CDC for the treatment of influenza.
meds that cause hyperthyroid
amiodarone (both hypo too) interferon (both) etc
screen macular problems
amsler grid test
acute bronchitis
an inflammation of the lower respiratory tract without underlying airway disease if they had COPD, it would be COPD exacerbation
top 2 HIV transmission risk
anal intercourse needle share during injection drug use
CCB risk
ankle edema nonDHP CYP340 3A4 HF, renal or hepatic caution
gen rule for Rx for elderly to avoid
anticholinergic r/t risk of confusion, urinary retention, constipation, visual disturbance, hypotension if not avoidable, choose the least amount of this effect
Pharm intervention to prevent recurrence of duodenal ulcer
antimicrobial therapy with PPI
cough if other measures fail
antitussive- codeine, dextromethorphan
when to test for visual acuity
any comprehensive PE on adult or child anyone with an eye complaint red eye, painful eye, new onset vision change refer to opthamology
if murmur radiates to neck assume____ until proven otherwise
aortic
retinal arteries vs veins thick vs narrow
arteries always narrower
(DPP-4) inhibitor when to use
as add on with metformin and SU expensive
chorionic villus
as advised 10-12 wks
Amniocentesis
as advised 15-20 wks
intervention in anaphylaxis
assess ABC IM epi- (anterior -lateral thigh) IV access, o2, monitoring supine position primary care: epi and 911
question stem: initially
assess b4 dx then plan, then intervene, then evaluate response to care. ADPIE
mgmt AOM peds
assess pain and if present tx watchful waiting without ABX is acceptable bec---low risk adverse outcome, high rate spontaneous resolution BUT follow up 48-72 hrs if child fails to improve
secondary HA
assoc with or caused by other conditions gen will not resolve until that is addressed
sulfa allergy
associated with thiazides, furosemide, acetozalamdimde
allergic rhinitis is like..
asthma in the head inflammatory IGE mediated environmental risks are similar
genital herpes findings
asymp or atypical but classic: painful ulcerated lesions with marked lympadenopathy
iron supp in peds
at 4-6 mo (2mg/kg/d) from milk >12 mo (16oz/d)
Stage A HF example and definition
at high risk for HF but w/out structural Dz or Sx Pt with HTN, athero, DM, obesity, metabolic or Pr using cardiotoxins or Fam hx of cardiomyopathy
number wet diapers/day baby
at least 6
when is small pos most contagious
at onset of rash. They are usually very sick and not able to move much. They are contagious until the last scab falls off
when hypo likely to occur with insulin
at peak
progestin and estrogen endometrium
atrophy/transformation proliferation- basically normal lining so opposites. Progestin is contraceptive
post infxn cough with QOL intefere
atrovent +ICS (1 wk)
Heart Murmur grade 6
audible without steth
AFIB in elderly avoid
avoid antiarrythmic drugs as 1st line ex: amiodarone etc inc risk of vtach, vfib, death, thyroid Dz better to do rate control ex: BB, CCB
osgood-schlatter disease intervention
avoid sports that involve heavy quad loading or deep knee bending time is the intervention
HA lifestyle modifications
avoid triggers exercise posture tinted lens
Nongonococcal urethritis and cervicitis tx
azythromycin
A healthy 6-year-old girl presents for care. Her parents request that she receive vaccination for influenza and report that she has not received this vaccine in the past. How many doses of influenza vaccine should she receive this flu season? A.1 B.2 C.3 D.4
b All children aged 6 months to 8 years who receive a seasonal influenza vaccine for the first time should receive 2 doses spaced ≥4 weeks apart.
A 22-year-old man is starting a job in a college health center and needs proof of German measles, measles, and mumps immunity. He received childhood immunizations and supplies documentation of MMR vaccination at age 1.5 years. Your best response is to: A. obtain rubella, measles (rubeola), and mumps titers. B. give MMR immunization now. C. advise him to obtain IG if he has been exposed to measles or rubella. D. advise him to avoid individuals with skin rashes.
b As with all vaccines, giving additional doses to patients with an unclear immunization history is safe.
SIDS prevent edu
back to sleep firm sleep surface room sharing no soft objects, loose bedding prenatal care no smoke exposure BF pacifier at nap and bed time ok avoid overheating
Why test blood culture for sepsis
bacteremia
acute epiglottitis
bacterial 2-7yo abrupt high fever, sore throat, dysphagia, drooling airway maint ENT CONSULT
Why test CBC with diff for sepsis
bacterial or viral shift
impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture
impetigo
bacterial skin infection characterized by isolated pustules that become crusted and rupture tx with topical antimicrobial- bactribam systemic if bad
ABX 1/4 tx failure if H influenzae
bactrim
click sound with sucking baby
bad latch reposition the baby lips should be out and mouth covers areola
yeast infxn men sx (3)
balanitis groin fold involvement scrotal excoriation
cardiac conditions which prophylaxis for dental is necessary and 1st line ABX
because of infective endocarditis (IE) : valve repair, previous IE, congenital HD, transplant Amox
urge incontinence tx
behavior therapy antimuscarinic
Harsh murmur where heard best example
bell or diaphragm aortic stenosis
hemangioma (infant)
benign tumor of endothelium rapid grow from beginning-6mo slow proliferation 6-12 mo involution 12mo- 3-6yrs
cost effective antibacterial in mild acne
benzoyl peroxide
when is referral to specialist necessary for HA
beyond scope need dx supported or clarified (ex: RA, lupus) complex health prob ongoing (CVD) fails to respond to standard EBP
EKG: big waves=
big LV
levothyroxine
bioidentical hormone Synthroid
giant cell arteritis diagnosis and tx
biopsy of temporal artery Don't wait for biposy start high dose Prednisone right away.
BB MOA
block adrenergic beta1 receptor sites blunt catecholamine response non cardioselective also block beta2 BP=HR(dec)xSV(dec)xPVR
Aldosterone antagonist MOA
block effect of aldosterone, so better regulate Na and water homeostasis and maintenance of intravascular volume BP=HRxSVxPVR (dec)
peripheral arterial disease
blockage of arteries carrying blood to the legs, arms, kidneys and other organs
Niacin why? effect
boost HDL lower TG
pyloric stenosis vs intussusception US is 1st line Dx
both
target organs for HTN
brain, cardiovascular system, kidney, eye
3 yr old remember
build a 3 tower block ride tricycle 3 word sentences can draw a circle
SDRI example and effect
buproprion usually as add on with SSRI best effect on improve mood but generally get partial response when only lift dopamine
venous insufficiency sx
burning, swelling, throbbing, cramping, aching, and heaviness in the legs, restless legs, leg fatigue, spider veins
prepatellar bursitis intervention
bursal aspiration 2nd line: ice and NSAID
autism developmental red flags 1+ warrants further eval
by 6 mo- no big smiles, warm, joyful by 9 mo- no back and forth share sounds, smile, expression by 12 mo- lack of response to name, no babble, baby talk, show, point by 16 mo- no spoken words by 24 mo- no meaningful 2 word phrases that arent imitating
Concerning hepatitis B virus (HBV) vaccine, which of the following is true? A. The vaccine contains live, whole HBV. B. Adults should routinely have anti-hepatitis B surface antibody titers measured after three doses of vaccine. C. The vaccine should be offered during treatment for sexually transmitted diseases in unimmunized adults. D. Serologic testing for hepatitis B surface antigen (HBsAg) should be done before hepatitis B vaccination is initiated in adults.
c
Which of the following should not receive vaccination against influenza? A. a 19 year-old with a history of hive-form reaction to eating eggs B. a 24-year-old woman who is 8 weeks pregnant C. a 4-month-old infant who was born at 32 weeks of gestation D. a 28-year-old woman who is breastfeeding a 2 week old.
c all members of the population age 6 months and older should receive annual immunization against seasonal influenza. those with an egg allergy that is only hives should be given the vax
valerian root
calms nerves. Avoid with liver disease
kava
can cause liver damage
2 months remember
can lift self up on 2 arms responds 2 sounds smiles when smiled 2
18 months remember
can name single word objects says no a lot copys adults
opioids for HA
can provide analgesia and are often prescribed for migraine rescue. These products are sedating and potentially habituating
functional incontinence
can't make it to the bathroom in time; every 1/2 hr or 1 hr bring patient to bathroom/ put on schedule
Sodium Glucose cotransporter-2 (SGLT2) example
canagliflozin dapagliflozin
tx with clotrimazole cream
candida
pseudohyphae
candida vulvovaginitis
Knee OA tx Sg
cannot recc strong about debride arthro
in hyperthyroidism, what happens to the mentation
cant make sense, mind racing
in hypothyroidism, what happens to the mentation
cant make sense, thoughts too slow
Isotretinoin (Accutane)
capsules, various strength inhibit sebum for severe only prob derm referral if doesnt respond to other tx 4-6 mo, repeat after 2 mo if necc monitor mood need a lot of edu and know about AE very teratogenic!!!!!!!! Need contraception!!!!! iPLEDGE so just refer
post menopause risk factor
cardiovascular
carotid bruit vs radiating murmur
carotid: softer, unilateral, diff than chest sound radiating is opp
Rubella
cause by rubella virus fever, sore throat, malaise nasal discharge post cerv and postauricular lymph beg 5-10 d prior to onset and present during rash 3 day measles notify pub health and get confirmation
toxic adenoma
cause hyperthyroid benign, metabolically active thyroid nodule
Graves disease
cause hyperthyroid, most common autoimmune multisystem presentation including exopthalmus, tachy, proximal muscle weakness, goiter
hand, foot, mouth Dz
cause: coxsackie F, malaise, sore mouth, anorexia, 1-2 d later lestions poss conjunctivits, pharyngitis lasts 2-7d oral/fecal or droplet highly contagious incubate 2-6 wks supportive tx
infectious mono
cause: epstein barr maculopap rash, fever, purple white pharyn exudate, malaise, lymph, hepatic and splenic tenderness test with monospot, leukopenia with lymphocytosis
Diptheria
caused by Corynebacterium diphtheriae, a gram-negative bacillus typically transmitted from person- to-person contact via respiratory droplets or cutaneous lesion. This organism causes a severe illness involving the respiratory tract, including the appearance of pseudomembranous pharyngitis and possible airway obstruction. Owing to high immunization rates, a confirmed case of diphtheria has not been reported in the United States for more than a decade.
post-radioactive iodine tx
causes hypothyroid S/P graves disease tx, thyroid cancer tx
CCB MOA
causes vasodilation BP=HRxSVxPVR (dec)
Migraine specific meds education
caution preggo and CVD, HTN
Gonococcal urethritis and cervicitis tx
ceftriaxone IM and azithromycin PO or cefixime PO if cant do IM
Acute Bacterial Prostatitis <35yo tx
ceftriaxone and doxy
anemia
characterized by dec in number of rbc or hemoglobin content caused by blood loss, deficient erythropoesis, excessive hemolysis, or a combinations So either DEC RBC or Hb content Caused by loss, cant make new, or a lot of cell death or a combo
HMG-CoA reductase inhibitor risk and edu
check hepatic enzyme prior for baseline DM2 risk inc slightly with high intensity statin no grapefruit juice AE: rhabdo, myositis
lead poisoning tx
chelation therapy for higher levels <10=education 10-19=repeat 1 mo +edu 20-44= repeat in 1wk, assess hazard, edu, health department 45-69- chelation >70- hispitalize
baby gonococcal conjunctivitis prevention
chemo prophylaxis -silver nitrate or erythromycin when it was born
angina pectoris
chest pain
when evaluating an adult with a cardiac murmur ask about..
chest pain HF sx palpitations syncope activity intolerance
impetigo population etc
children in tropical or subtripical more in northern in summer months peak 2-5 yr old
doxy tx STI
chlam or syph
sequelae Hep B
chronic Hep B hepatocellular carcinoma hep failure
most common sx of COPD
chronic cough, chronic sputum prod, activity intolerance, sx usually progress over time
wheal
circumscribed area of skin edema ex: hive
allergic rhinitis (relieve sx)
claritin, zyrtec intranasal antihistamine ocular antihistamine-olopatadine
Asthma assessment
classify severity at initial visit control in follow up visits identify precipitating and exacerbating factors and comorbidities identify pts high risk for exacerbate and death reg assess pt and family education and skills incl meds and technique
topical ABX for acne
clinda, erythro etc mild to mod most effective for mild less effective than Oral Abx for mod-severe use in combo with benzoyl and/or tretinoin
suicide HA
cluster
hydrocele
collection of serous fluid that causes painless scrotal swelling, easily recognized by transillumination
acne tx results in reduction of androgen levels
combo pill
Atrophic vaginitis pH, discharge, odor
comes from estrogen deficiency >5 Scant/white/clear no odor
asthma
common chronic disorder of the airway that is complex and characterized by variable and recurring sx, airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation
most effect tx hot flashes (vasomotor sx)
conjugated estrogen
chemosis
conjunctival edema
reactive arthritis
conjunctivitis, urethritis, arthritis cant see cant pee cant climb a tree (ankle/knee)
Lumbar radiculopathy intervention
conservative tx as with LS strain
port wine lesion infant mgmt
consider sturge weber syndrome pulse dye laser therapy to lighten refer if eyelids or assoc with Sz
common PE findings in pneumonia
consolidation pleural inflammation (pleurisy)
in hypothyroidism, what happens to the stool pattern
constipation
impetigo
contagious disease usually consists of discrete purulent lesions usually on exposed areas of body, most frequent face and extremities.
HFpEF tx
control sx, improve HRQOL, prevent hospital, prevent mortality identify comorbidities tx: diuresis to relieve sx of congestion guideline driven for diff comorbidities
progestin and estrogen cycle
controls it
Qs to consider for therapuetic goals for DM2
correction of FG? post prandial? action on insulin resistance? inc insulin available? offload glucose? hypoglycemia risk?
naegele's rule
count back 3 months from first day of last menstrual period and add 7 days and 1 year
crohn vs UC location
crohn: mouth to anus UC: colon only
venous insufficiency etiology
damage venous valves and can result in thrombus formation and/or valve failure
lifestyle changes to lower cholesterol
dec LDL with plan sterols and stanols reduce saturated fat to <7% tot calories inc omega 3 esp for pt with CHD= EPA+DHA supp
risk of obese mom to mom
dec accuracy of surveillance post partum HTN Csection
involution
decrease in size
assess COPD
deg of airflow limitation spirometry for Dx FEV1:FVC<.70 post bronchodilator confirms persistent airflow limitation/COPD determine severity by FEV1 Alpha-1 Antitrypsin def screen
hemangioma (infant) mgmt
depend on location, risk of complication, scarring, ulceration slow growth---could use oral propranolol, systemic steroid watch/wait- thigh, upper arm
dysphonia
difficulty producing speech sounds, usually due to hoarseness
BV common complaint and Tx
discharge, foul odor, itch sometimes Anaerobes so.. Metronidazole topical or oral (flagyl) clindamycin vag cream
rocky mountain spotted fever
disease transmitted by American dog tick Caused by Rickettsia rickettsii Sx: rash on palms and soles (migrating to wrists, ankles, then trunk), HA, fever. Endemic to East Coast (in spite of its name).
port wine lesion infant
disorder of dermal capillaries sometimes assoc with other conditions
ASCVD algorithm statin
do they have ASCVD? yes- start high if under 75 and high or mod if over 75
esophageal stricture
doesnt usually bleed rather common fibrous band of tissue causing narrowing of esophagus, can be 1 or more and can form secodary to any esophageal damage, but esp reflux from anestheia, foreign body and medication
why no Nitrofurantoin in older adult?
doesnt work well with impaired renal function
BB and COPD
dont
clarithromycin and CYP
dont do it, it inhibits basically dont Rx, unless H.Pylori and even then make sure you know their med list
vegitative sx? low energy tx
dont give sedating med opp for high energy
vaccine schedule
dont memorize just read the footnotes to the schedules and tells me inclusion exclusions
hypothyroid intervention
dont need endo mostly tx with levothyroxine calculate body weight adult need more than older, but kids need most mcg/kg/d need to inc with preggo by at least 33% for all check TSH after at least 8 wks of tx
oral Abx for acne
doxy, eryth, bactrim use for mod-severe acne tx cont for 3 mo add 1-2 if necessary then taper while add topical Abx might need repeat tx
SSRI pt edu
drink lots of water might get a head ache tx with tylenol
rotator cuff eval test
drop arm test
Macular degeneration tx
dry form: prevention b/c few tx and develops over decades wet form: laser tx, injection antivascular growth factor develops quicker over months
desiccation
drying out
What type of PUD is classically described by the onset of burning epigastric pain 1 to 3 hours after eating that is relieved by food?
duodenal ulcer
Fibric acid AE
dyspepsia, gallstone, myopathy, rhabdo CI: renal or hepatic Dz
trich findings
dysuria, itch, vulvo irritation, dyspareunia, vag discharge, strawberry spots sometimes often without sx microscope: motile org and WBC alk pH
Tanner stage 2
earliest changes breast bud public hair scrotal change
when screen for gest DM
early as poss if risk factors incl PCOS hx all else 24-32 wks with overnight fast and OGTT
amsler grid test
early detect macular degeneration
in hypothyroidism, what happens to the heat/cold tolerance
easily cold
systolic murmur, likely pathologic next step
echo
antecubital foss location condition
eczema
second gen antipsychotic warning
elderly inc death
Peripheral Neuropathy Dx
electromyography or biopsy med hx
viral meningitis
elevated WBC, predominantly lympocytes, normal CSF protein, normal CSF glucose, negative gram stain. similar symptoms as bacterial just not as severe and less risk for mortality
atopic dermatitis infant mgmt
elim triggers hydrate control itch
seborrheic derm infant tx
emmolient scalp tx--petrolium ketoconazole for other parts of the body common-3wk-12 mo
epididymoorchitis >35yo or having anal intercourse cause and presentation
enterobacteriaceae (coliforms) irritative void, fever, painful swelling, infertility post infxn
Acute Bacterial Prostatitis (uncomplicated with no risk for STI) cause and presentation
enterobacteriaceae (coliforms) irritative void, suprapubic, perineal pain, fever, tender, boggy prostate, leukocytosis
male GU infxn (2)
epididymoorchitis acute bacterial prostatitis
NSAIDs causes heartburn and small amount of red blood:
erosive gastritis
giant cell arteritis initial response and confirm
erythrocyte sedimentation rate confirm with biopsy
chlamydial conjunctivitis tx
erythromycin PO 2wks r/t pneumonia risk
BV pH, discharge, odor
etiology unclear >4.5 thin, homogenous, white/gray, adherent, often inc fishy
slit lamp
eval anterior eye structures, including cornea, conjunctiva, sclera and iris
GLP-1 Agonist example
exenatide (byetta) liraglutide albiglutide
small pox arch of sx
exposure 7-17 days incubation with no sx and not contagious prodromal fever- 101-104, HA, V, ache rash, starts on tongue, spread to limbs, 24 hrs temp dec day 4 thick lesions diff lesions from chicken pox bec small pox lesions are all same stage
conjunctiva pallor
extreme finding in anemia
selective cholesterol absorption inhibitor example
ezetimibe
greatest place of absorption for topical agent
face
neonatal jaundice first seen in...
face then to body
acne infant
face, nose, forehead usually lasts 1-2 mo self resolving
3 ways to dz DM2
fasting >126 random >200 with symptoms inc 3Ps or wt loss or hyperglycemic crisis (OGTT 2 hr plasma >200 after 75g glu)--most expensive way A1C>6.5
Route of transmission Hep A
fecal oral
how is polio transmitted
fecal-oral
TORCH
fetal prob acronym toxoplasma gondii, other infxn, rubella, CMV, herpes
Atrophic vaginitis microscope
few or absent lactobacilli
algorithm for the management of acute bacterial rhinosinusitis
figure 5-6 in fitzgerald book
Secondary hyperparathyroidism diagnosis
find elevated serum and PTH presence of severe renal dysfunction often on dialysis
normal prostate finding
firm, smooth, tender tip of nose
infancy age
first yr
patch
flat discoloration greater than 1 cm in diameter example is vitiligo
macule
flat discoloration less than 1 cm in diameter example is a freckle
communicating hydrocele presentation and tx
fluid filled transilluminates nontender testes normal fluid amt changes throughout the day with position NEEDS Sg
OME definition
fluid in middl ear without sx of ear infxn
SSRI from most to least energizing
fluoxitine sertraline citalopram paroxitine
most drug drug interaction potential SSRI
fluoxitine and paroxitine (CYP)
Niacin AE
flushing, hyperglycemia, hyperuricemia, upper GI contraindicate- liver Dz, gout, peptic ulcer
inhaled corticosteroids (ICS)
fluticasone mometasone budesonide beclomethasone pref for persistent asthma need consistent daily use for optimal effect (NOT PRN)
acne vulgaris patho
follicular epidermal hyperproliferation leads to follicle plugging and excess sebum production
Why test stool for sepsis
for dx of shigella or other form of infectious diarrhea
Ergotamines and ergot derivatives
for migraines only potential vasoconstrictor so CI with CAD, angina, preggo available as oral and sublingual, suppositories, injectible, nasal can come with combo like caffeine etc
outpatient tx diverticulitis when organism primary and alternative tx
for mild (only) and need ABX for G- anaerobic and aerobic Enterobacteriaceae Pseudomonas aeruginosa Bacteroides enterococci Primary: metronidazole+bactrim cipro or levoflox Alternative: augmentin or moxif
SSRI 1/2 life
for older adults want shorter half life paroxitine is shortest but is more sedating and more AE
phimosis
foreskin cannot be pulled back to expose the glan
most common known cause of autism
fragile X can do blood test for carrier
in hyperthyroidism, what happens to the stool pattern
frequent, low volume, loose
candida vulvovaginitis pH, discharge, odor
from candida albicans <4.5 white, curd, cottage cheese no odor usually
primary skin lesion
from disease process itself not altered by outside manipulation, treatment, natural course of disease ex: vesicle
radiate to axilla think
from mitral valve
systemic corticosteroid use is rf for duodenal or gastric ulcer
gastric duodenal would be H pylori
Tretinoin (retinoic acid)
gel, cream keratolytic normalizes hyperkeratinization dec cell cohesion inc cell turnover anti inflammatory for all acne types might peel AE: need sun screen
Fibric Acid derivative effect and example
gemfibrozil, fenofibrate HDL and TG
younger than 6mo how protect from flu
give people around the baby the shot cacooning
glipizide or glyburide for older adult
glipizide bec glyburide has too long 1/2 life
Sulfonylurea (SU) example
glipizide glyburide glimepiride cheap $4
HFrEF tx
goal: control sx, patient edu, prevent hosp and mort Drugs: diuretics, ACE/ARB, BB, Aldosterone antag some get other things like digitalis etc or CRT, ICD, Sg
Stage B HF tx
goal: prevent sx and further dmg drug: ACE/ARB BB sometimes ICD or revascularization Sg refer
ceftriaxone tx STI
gono
Acute Bacterial Prostatitis <35yo cause and presentation
gono and chlam irritative void, suprapubic, perineal pain, fever, tender, boggy prostate, leukocytosis
epididymoorchitis <35yo cause and presentation
gono and chlamy irritative void, fever, painful swelling, infertility post infxn
PID cause
gonorrhea or chlamydia
redness at the first metatarsophalangeal joint
gout bec it is thermally cool and allows the urate crystals to precipitate out
impetigo cause
gram positive group A strep or staph aureus
4 causes hyperthyroid
graves disease toxic adenoma thyroiditis select meds
how often use home 02
greater than 15 hrs/day
Group1-2 <1_ exacerbation/yr COPD
group A- low risk less sx SAMA or SABA Group B- low risk but more sx LAMA or LABA
Gold 3-4 2+ exacerbation/yr COPD
group C- high risk/less sx ICS+LABA or LAMA group D- high risk/more sx ICS+LABA or LAMA can use both (or) together but only if alone not working
atopic dermatitis infant presentation adult diff
hands, feet
acute bronchiolitis peds
happy wheezer mild ill 3 mo-3 y viral cause: RSV lasts 3 wk serious in early infancy NOV-APR supportive tx
3 common hypothyroid etilogies
hashimoto post-radioactive iodine tx select meds
DD of wheeze in kids Lower airway obstruction
hear on expiration acute bronchitis acute bronchiolitis asthma
DD of stridor in kids caused by upper airway obstruction
hear on inspiration croup foreign body congential peritonsilar abscess acute epiglottitis
orthopnea=
heart failure most of the time
in hyperthyroidism, what happens to the heat cold
heat intolerance
systemic corticosteroids for HA
helpful with severe migraine and cluster not recc if more than 1x/month
blowing murmur where heard best example
high use diaphragm aortic regurgitation
effective ABX for S.Pneumoniae (DRSP)
high dose amox floroquinolones
baby hearing pitch best
high pitch
high vs mod statin therapy
high- lowers LDL >50% mod-lowers LDL 30-50%
common other sx of adult with GERD
hoarseness, recurrent cough, chronic pharyngitits
if the gut cant work well like no bowel sounds, gut distended
hospital
fifths disease
human parovirus B19 3-4d mild flu, then 7-10d red rash begin on face (slapped cheek), spread to trunk and extremeties supportive tx
in hypothyroidism, what happens to the reflexes?
hung up patellar reflex, slow arc out, slow arc back, overall hyporeflexia hung up, knee tapped goes out slowly but comes back even slower
normal TM
hx: no complaint findings: -Pale, gray, transluscent appearance -Cone of light and bony landmarks visible -Mobile with pneumatic otoscope
Aldosterone antagonist risk
hyperkalemia risk, esp with ACE/ARB or volume depletion including excessive diuresis most often used in HF tx Gynecomastia risk with prolonged use AE is why its 4th line, otherwise very potent
keratosis pilaris infant
hyperkeratination of hair follicles goose flesh, rough skin asymp except some itch no mgmt except lotions
in hyperthyroidism, what happens to the reflexes
hyperreflexia
air trapping in COPD and asthma sx
hyperresonance dec tactile fremitus wheeze(expir first) low diaphragm inc AP diameter all this: COPD consistent presence, Asthma only during exacerbation
low TSH (<0.15) FT4=79 so high
hyperthyroid
During a high school football game, a young athlete collapses and dies immediately. What type of cardiac disease did he have?
hypertrophic cardiomyopathy less likely but maybe blunt trauma to heart
(SGLT2) risk
hypo risk genital mycotic infxn UTI inc urination mod wt loss discontinue with renal impair (cant offload sugar) inc risk DKA
Sulfonylurea (SU) risk
hypo risk esp in elders or impair renal beta cell fail after many yrs and older adults and not as good with severe hyperG
high TSH (84) FT4=3, so low
hypothyroid
hashimoto thyroiditis
hypothyroid autoimmune Most common cause of goiter and primary hypothyroidism in adults in developed countries. Autoimmune disorder with circulating antithyroid antibody.
talar tilt
identifies ligamentous instability (particularly calcaneofibular ligament) Ankle special test for Deltoid and CF ligament
<9yo tanner 2 male
idiopathic 40%, maybe CNS tumor
Tx DM2 dual therapy
if A1C goal not receive after 3 mo monotherapy Next: SU (low cost) or Next: TZD (younger and nocomorbidity) Next: DPP4 (high cost) (postprandial) Next: SLG2 (high cost post prandial) Next: GLP (post prandial) Next: insulin (a little too much for dual)
tx DM2 triple therapy
if A1C not at goal after another 3 mo Met+SU+ (TZD or DPP, SGL, GLP or insulin) DPP4 is good 3rd drug after Met+SU because good post meal and that is the prob with control GLP is decent especially if the patient is also obese r/t wt loss
start insulin step 3
if A1c not at goal target post prandial glu with bolus premeal
when to use prophylactic tx for HA
if abortive tx used freq or if inadequate. goal is to reduce 50% number of HAs First, look at whether pt uses estrogen, progesterone, vasodilators and eliminate if poss
impetigo treatment
if few lesions, use topical tx with mupirocin (bactroban) if numerous lesions or not responding to bactroban, use oral antimicrobials effective against S Aureus or strep pyrogenes
elderly woman with freq UTI
if not sx, leave em be if sx, topical vaginal cream: low dose estrogen
PID tx
if suitable for outpatient tx: ceftriaxone IM and doxy BID 14d with or without metronidazole BID 14d
wt gain during preggo
if under wt--28-40 normal 25-35 overweight-15-25 obese 11-20
Angle closure glaucoma tx
immediate refer to optho rapid pressure reduce via meds and maybe Sg
atopic dermatitis infant
impaired epidermal layer allowing irritants dec water content because of poor barrier itch/scratch makes worse maybe genetic
who shouldnt be on high intensity statin
impaired renal over 75 bec highest risk for rabdo
annular
in a ring formation ex: Erythema migrans in Lyme disease
most important time to screen for hearing defects in young child
in first days of life
when endoscopy with GERD
in presence of alarming findings dysphagia, odynophagia, involuntary wt loss, hematemesis, melena, chest pain, choking screen pts with high risk for complications
linear
in streaks ex: poison ivy
Giant cell arteritis diagnosis
inc CRP and ESR definitive dx with biopsy
primary hyperparathyroidism etiology
inc PTH Etiology: overactivity of 1+ of 4 parathyroid glands, by enlargement (hyperplasia), adenoma (benign), or malignant tumor
tx COPD exacerbation
inc SABA PRN add on LABA or LAMA if not on if baseline FEV1<50% (gold 3&4) then add systemic steroid 5-10d consider ICS if not on smoke cessation ABX if inc dyspnea, inc sputum volume and inc sputum purulence BUT EVIDENCE VARIES
airflow obstruction that is at least partially reversible what is monitor by FEV inc from baseline
inc in FEV1 of at least 12% from baseline post SABA
displaces usually indicates..
inc in LV volume pressure overload, poor control HTN
Sulfonylurea (SU) mech of action
inc insulin release from pancreatic beta cells fasting and postprandial
(DPP-4) inhibitor mech of action
inc insulin release mostly post prandial
GLP-1 Agonist mech of action
inc insulin release postprandial slows gastric emptying so wt loss and appetite suppression
why no zolpidem (ambien) in older adult?
inc risk fall/fracture
why no sertraline in older adult?
inc risk hyponatremia all SSRI too, check Na in 1 mo if older adult on SSRI
Fish oil AE
inc risk of bleed r/t antiplatelet
communicating hydrocele cause
incomplete seal of peritoneal cavity at inguinal so communication b/t abdomen and scrotum
PPI indication, new info and risk vs benefit
indicated for GI, duodenal ulcers, GERD, part of H.Pylori Tx AND long term use for severe GERS, erosive esophigitis, NSAID induced ulcer prevention Long term PPI use --rebound hypersecretion in>2 mo consider taper and QOD use. can take them off PPI and use BID ranitidine --Fe and B12 deficiency --Inc Fx risk -Mg absorption dec --inhibits CYP, dec activity of PLAVIX
Meningitis
infection of meninges, CSF, and ventricles can be bacterial, viral, fungal etc most common cause is encephalitis, which can cause flu like sx, fever, HA, confusion, sz, sensory or motor impairment
encephalitis
inflammation of the brain Need imaging, CT/MRI LP
epididymoorchitis
inflammation of the epididymis and testicle
balanitis
inflammation of the glans penis
aphthous stomatitis
inflammation of the mouth with small, painful ulcers
Acute Rhinosinusitis
inflammation of the mucosal lining of nasal passages and paranasal sinuses lasting up to 4 wks caused by allergens, environ irritants, and or infection (virus majority)
otitis externa treatment
inflammation of the outer ear Eardrops: cipro; acetic acid drops might be effective in mild episodes; antibiotics with steroid otic drops are the treatment of choice. Symptoms should be improved in 7 days but can take up to 2 weeks. ABX: cipro
pyelonephritis
inflammation of the renal pelvis and the kidney
inhaled muscarinic antagonist
inhaled anticholinergic emergent role in asthma well established for COPD normally for prevention not tx ex: ipratroprium bromide=SAMA tiotropium bromide=LAMA
progestin and estrogen ovary and pituitary
inhibits
*too much ibuprofen and HCTZ
inhibits effect of diuretic
initial response to Bells Palsy with no other sx or hx
initiate a course of oral corticosteroids lubricating eyedrops maybe biting cheek
tx acute gout
initiate pharm within 24hrs onset NSAID, steroids, or colchicine PO,
GLP-1 Agonist how use
injection only
most common vertigo etiology
inner ear disturbance
why PCOS and DMII
insulin resistance
Thiazolidinedione mech of action
insulin sensitizer fasting and post prandial min hypo risk
metformin mech of action
insulin sensitizer reduce hepatic glu prod and intestinal glu absorption action on fasting and postprandial
bladder cancer presentation
intermittent painless gross hematuria DD: kidney stones but will have pain
IBD basic
intestinal ulceration, inflammation, detectable microscope or macroscope
adjunct tx to relieve nasal congestion in a 32yo man with ABRS and allergic rhinitis includes all except oral first gen antihistamine intranasal corticosteroid oral decongestant intranasal anticholinergic
intranasal corticosteroid
allergic rhinitis tx (control sx)
intranasal corticosteroids flonase triamcinolone LTRA not first line montelukast Mech of action: inflammatory mediator prevention
pyloric stenosis vs intussusception sausage shaped abdominal mass
intussusception
pyloric stenosis vs intussusception usually in first year of life
intussusception
pyloric stenosis vs intussusception loose stools, current jelly appearance
intussusception if it does something weird to the stool normally lower GI
Lumbar radiculopathy etiology
irritation or damage of neural structure like disks
Gonococcal urethritis and cervicitis findings
irritative voiding and discharge often without sx large # WBC on microscope
Nongonococcal urethritis and cervicitis findings
irritative voiding sx sometimes discharge often without sx large number WBC with microscope
PID findings
irritative voiding sx, fever, abd pain, cervical motion tenderness, vag discharge poss tubal scarring with inc for ectopic preggo and/or infertility
why prevnar
it is less valence (13) but it is a conjugate vaccine and therefore more effective than pneumovax
Atrophic vaginitis common complaint and tx
itching/burning discharge but often w/out sx topical or vaginal estrogen if sx or recurrent UTI not oral estrogen
candida vulvovaginitis common complaint and tx
itching/burning/discharge -Azole, antifungal oral or vaginal (monostat)
physiologic jaundice
jaundice in the absence of liver disease
minimal dehydration tx peds
just sip fluids requently
milia infant
keratin and sebacious material on nose and cheeks no tx resolve spont in a few weeks
elderly kidney and liver
kidney weight dec hepatic blood flow dec
most common form of sex hormone aneuploidy in males
klinefelter
lachman maneuver is for
knee instability including ACL
how to think about thyroid
know patho and think conceptually
aspirin for primary prevention of cardiac events >80
lack of evidence
ataxia
lack of muscle coordination
metformin risk
lactic acidosis rare (already hep or renal impairment or old age >80) min hypo risk
fragile X syndrome
large forehead, ears and jaw. avoid eye contact large testes learning diff
macroorchidism
large testes
metabolic syndrome
large waistline hypercholesterolemia Low HDL High BP High glucose
creatinine rise and kidney function
late marker
burn blister tx
leave intact when possible debride larger with thin walls that prevent movement of a joint or likely to rupture
if unable to palpate PMI
left lateral decubitus position enhancement roll to L side could have thick chest wall, obesity, COPD
senile cataracts
lens clouding results in progressive vision dimming, distance vision probs, close vision ok RF: smoke, poor nutrition, sun, steroid maybe Sg or lens implant can help
why elderly distribution of med diff why do they get dehydrated
less % body weight is water
COC and hx gastric bypass
less benefit with COC r/t not having a duodenum where pill goes
beta and elderly
less effective consider anticholinergic instead of Beta 2 consider CCB instead of BB
findings consistent with acute appendicitis
leukocytosis with neutrophilia and bandemia positive obturator and psoas sign 12 hr hx of epigastric discomfort and anorexia that gradually shifts to nausea and RLQ pain
atopic dermatitis infant present from child to 12yo
lichenification of flexure surfaces
VZV and shingles
lies dormant in sensory nerve ganglia 15% with hx of pox get shingles less chance with VZV vs wild indiv w/ shingles cant transmit shingles but can transmit pox if other with no vax or Dz hx
Reyes syndrome
life threatening swelling of brain and liver, most often affecting children and teens. linked to aspirin use. hx of febrile viral illness(chickenpox, influenza) and aspirin
Rf for osteoporosis and Fx
lifestyle genetic hypogonadal endocrine disorder GI Dz Hemo Dz RA and autoimmune CNS Dz etc Certain meds
venous insufficiency Tx
lifestyle changes compression stockings sclerotherapy or ablation
PAD Tx
lifestyle mod tx to control BP, Chol, BS aspirin to prevent clot
IBS intervention
lifestyle mod- diet, fiber, fluid, exercise meds: indicated by sx antidiarrhea, promotility, select ABX, probiotics
IBD intervention
lifestyle mod- diet, fiber, fluid, exercise (less sure of fix) antiinflammatory med- aminosalicylates, steroid as indicated immune modulators if no response to antiinflammatory Sg and monitor malignancy
SSRI best effect
lifting mood smooths out mood
hemangioma (infant) presentation
light port wine stain
mongolian spot infant mgmt
lighten over time dissapear over time no tx needed
conductive hearing loss
like cerumen impaction
if derm patient is otherwise well
likely condition limited to skin with few to minor sx such as: rosacea, keratosis pilaris, seborrheic dermatitis
HA analgesic education
limit 2 tx days per wk to avoid rebound use with triptan to enhance relief
ACEI and ARB example
lisinopril enalapril Losartan
meds that cause hypothyroid
lithium, amiodarone, interferon etc
CYP 450
liver enzyme system that metabolizes drugs for faster excretion
tylenol adverse effects
liver failure with high doses, and kidney damage with overdose
fluoxetine 1/2 life and drug drug potential
long many
TIA tx
long term anti platelet therapy- could be aspirin, clopidogrel, aspirin+extended release dipridamole
6 months remember
looks like number 6 when sitting up rolls back to tummy and back
in hyperthyroidism, what happens to the weight
loss 5-10lbs debilitating, its fat muscle and bone so older adults dont do well with this
ulcer
loss of epidermis and dermis ex: pressure sore
atrophy
loss of skin markings and full skin thickness ex: Area treated excessively with higher potency corticosteroids
Anosmia
loss of smell
rumble murmur where heard best example
low use bell mitral stenosis
DXA osteopenia
low bone mass BMD b/t 1.0-2.5 SD of young normal T score b/t -1.0 and -2.5
(DPP-4) inhibitor risk
low hypo risk
GLP-1 Agonist risk
low hypo risk N/V (r/t slow gastric emptying) rare pancreatitis do not use with gastroparesis, renal or pancreatic impair
thrombocytopenia
low platelet count What is the most common: Cause of abnormal bleeding?
thiazide diuretics MOA
low volume sodium depletion that leads to PVR reduction so BV=HRxSVx PVR (dec)
loose stool Q=
lower GI
cardiac lower and higher pressure
lower is R side (venous) higher is L side (arterial)
(SGLT2) mech of action
lower plasma glu levels by inc glu excreted in urine mostly postprandial
med with warning of QT prolong and inc CV death
macrolide
risk of obese mom to fetus
macrosomia, congenital, hypogly, dec success BF, preterm, mortality
etiology- central vision loss
macular degeneration
acute HIV infxn peds
maculopap rash, F, mild pharyngitis, ulcerating oral lesions, D, diffuse lymph consult
Tertiary prevention
management of an established disease. minimize disease medications and lifestyle modification to normalize aimed at improving or minimizing disease-related symptoms.
pathologic split S3 significance where heard best
marker of ventricular overload and/or systolic dysfunction heard in early diastole low pitch For Dx of HF=look for Dyspnea, Tachy, crackles
S1 heart sound significance where heard best
marks beginning of systole around the closing of mitral and tricuspid valves at apex with diaphragm "Lub" dub if cant tell, carotid pulse is simultaneous
S2 heart sound significance where heard best
marks end of systole around the closing of aortic and pulmonic valve best heard at base with diaphragm Lub "Dub"
excoriation
marks produced by scratching ex: Seen in areas of pruritic skin diseases
orthopedic assessment with systemic sx
maybe RA, SLE, polymyalgia rheumatica etc
test meniscal tear
mcmurray
tonometry
measurement of intraocular pressure, glaucoma screen test
free t4
measures unbound metabolically active portion of thyroxine for f/u to confirm hypo and hyper dx
psoriasis tx 1st line
med potency topical corticosteroid 2nd line- vit D derivative cream
mongolian spot infant present
melanocytes in dermis blue/black to grey macular lesions on back and butt mostly
mild cognitive impairment
memory disorder, usually associated with recently acquired information, that may be an early predictor of Alzheimer's disease
dementia with lewy body
memory loss and thinking problems common in Alzheimer's but are more likely than people with Alzheimer's to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and muscle rigidity or other parkinsonian movement features.
Aspirin use (low dose)
men>50 women>60 with DM and 1+ CVD RF like HTN, smoking, Fam hx
clicking or locking of the knee indicates what diagnosis
meniscal tear
in hypothyroidism, what happens to the menstrual
menorrhagia
biguanide example
metformin
when are cluster HA most common
middle aged men esp with etoh and tobacco
Duodenal ulcer treatment
might need upper endocscopy fecal H.Pylori test antibiotic therapy (metronidazole, tetracycline, amoxicillin or clarithromycin) with proton pump inhbitor
non severe AOM peds
mild otalgia <48 hrs OR F <102.2 in past 24 hrs
theophylline
mild- mod bronchodilator req periodic monitoring of levels mult drug-drug interaction potential stop using for asthma, i know its cheap
when tx dehydration in peds with ORT
mild-mod dehydration can do in office if vomit, add ondansetron to prevent and keep down
selective cholesterol absorption inhibitor risk and edu
minimal TG effect well tolerated most often Rx with another agent like statin
ACEI ARB MOA
minimize angiotensin II effect potent vasoconstrictor that also stimulates adrenal catecholamine release does this by minimizing AGII production (ACEI) or blocking its action (ARB) so BP=HRxSVxPVR (dec)
how long time out
minute for every year of life
osgood-schlatter disease cause
mismatch of connective tissue with bone growth bec most common in kids going through growth spurt
Primary hyperparathyroid clinical presentation
moans, groans, stones, and bones with psychic overtones low E, poor concentration, memory, depression, osteoporosis, insomnia, GERD, dec libido, hair loss, bone and joint aches. Kidney stones, HTN, arrythmia, AFIB, liver, ABN protein
Heart Murmur grade 3
mod loud without thrill about same as S1S2
when delay immunization
mod-severe illness with or without fever if youre thinking of admitting to hosp or ED
severe AOM
mod-severe otaliga OR Otalgia >48h OR Fever >102.2
Purulent (Abscess/carbuncle/furuncle) tx plan
moderate- I&D C&S empiric Rx- Bactrim or Doxy If results of C&S- MRSA- Bactrim MSSA- Doxy or cephalexin Mild- I&D
Non purulent (cellulitis/erysipelas/impetigo) tx plan
moderate- IV Rx Mild- more often in primary care Penicillin VK Cephalexin Dicloxacillin Clindamycin
selective cholesterol absorption inhibitor effect
modest LDL reduce well tolerated
BB risk
monitor worsening airway obstruction taper discontinue 10-14 d
leukotriene receptor antagonists (LTRA) leukotriene modifiers (LTM)
montelukast additional benefit with allergic rhinitis most often used with ICS but 50% as potent
chronic blood loss (anemia)
more common in primary care but can be chronic from erosive gastritis, menorrhagia, GI malignancy etc Iron from RBC wasted can cannot be recycled
<7yo thelarche
most common disorder could use GnRH agonist to delay refer
reduced RBC production
most common in primary care setting Nutrition- B12, folic acid, anemia of chronic disease (ACD), bone marrow suppression, use of certain meds like PPI (B12 and Iron), Metformin (B12), reduced erythropoetin production (Chronic renal failure)
common causes for stroke
most common is cerebral ischemia then cerebral hemorrhage, them subarachnoid hemorrhage
mod acne dx and tx
most kids with problematic acne 20-100 comedones 15-50 inflammatory lesions 30-125 total oral Abx with topical retinoid
postitive coombs test and Rh neg mom =
mother has autoantibodies against Rh pos RBC so mom can attack, need rhogam
confluent or coalescent
multiple lesions blending together ex: multiple skin conditions
15 year old 1 day hx of sore throat, swollen gland, LGF, and rash (diffuse, maculopapular, mild tender post cerical and postauricular lymphadenopathy) pharyngeal erythema w/out exudate no immunization since 6 mo
multisystem so prob viral posterior lymph not connected to sore throat immu- missed varicella and MMR etc A: Rubella tx sx
Sx low Mg and Dx and Tx
muscle cramp, heart palp, dizzy, tremor, Sz --dig tox risk do 24h urine Mag to test Tx with elemental Mag
candida vulvovaginitis microscope
mycelia, budding yeast, pseudohyphae w/KOH
hypertensive retinopathy
narrow branches
fissure
narrow linear crack into epidermis, exposing dermis ex: split lip, athletes foot
pulmonary hypertension murmur
narrow split S2 tricuspid regurgitation murmur SOB R side hypertrophy
stenosis
narrowing
1st gen antihistamine can help alleviate all except sneezing nasal congestion rhinorrhea itchy, watery eyes
nasal congestion
cholinesterase inhibitor AE
nausea and diarrhea
Hemogram evaluation in anemia
need CBC with RBC indicies dont need CBC w/diff look at HCT, Hb, RBC values should be proportionally decreased Normal H&H ratio=1:3 ex: 10g/dl=30%, 12g/dl=36% Exception: HCT artificially elevated with major dehydration. Normally HCT is circulating blood dependent, Hb is not
pregnant woman 3rd tri TDAP
need despite if prior immunize to protect newborn pertussis is dangerous in first 3 mo of life so this helps
burn on genital
need specialty burn care
effective ABX for H.Influenzae
need those with activity against G- and stable against beta lactamase Cephalosporin, Augmentin, macrolide, fluoro, doxy
systolic murmurs likely benign if..
neg hx low grade <_3 no radiation S1S2 ok no heave, thrill PMI WNL soften or gone with supine to stand
reticular
netlike cluster ex: multiple skin conditions
2nd gen antihistamine examples and mech of action and AE
newer or 2nd gen ex: Loratidine (Claritin), Clarinex, Cetirizine (Zyrtec), Allegra, Xyzal Do not easily cross BBB so lower rates of sedation. Little anticholinergic effect so less drying which is bad but also less negative effects on cognition, especially in older adults
A 17 year old female patient presents to your office with her mom. The patient complains of irritated and inflamed skin on her ear lobes. The patient reports that she recently had her ears pierced and has started wearing earring for the first time. What condition do these findings suggest?
nickel allergy
lumbar spinal stenosis DX and TX
no dx initially >1mo=MRI or EMG, or nerve conduction velocity Tx: PT, NSAID, steroid inj
erythema toxicum neonatorum infant
no etiology sometimes at birth/48hrs resolve by day 7 rash, progress to pustular lesion MGMT- observation
H pylori and GERD
no indicated no connection
DM retinopathy without fluid leak or bleed presentation and intervention
no vision complaint prevent progression with DM control (also HTN and HLD)
prostate cancer finding
nodular, firm, nontender usually lesions not palpable until disease advanced
Intussusception tx
non operative sometimes fixes itself hyrostatic or pneumatic enemas
baby has painless, tense, non reducible relatively symmetric scrotal enlargement that brightly and evenly transilluinates and doesnt change throughout the day
noncommunicating hydrocele its fluid, thats why looks like that, will go away without tx almost without exception
Chronic disease marker Hep A
none as it doesnt exist
sequelae Hep A
none, survive or die but low mortality rate
abundant WBC vaginal
nongono cerv
Bile acid resins risk and edu
nonsystemic AE: GI, constipation, dec absorption of other drugs so take separately
presbycusis
norm associate with aging symmetric and slowly progressing and high frequency
young baby with physiologic galactorrhea, breast engorgement
normal, present in 5% of newborns onset at 3-4d/life maternal hormone causes resolves in about 2 mo dont need further assessment
lead poisoning clinical presentation
normally <6yo few sx if not severe severe- anorexia, constipation, abd pain
Bells Palsy
normally no other sx than the paralysis cause is unknown often linked to viral infxns temporary, recovery by 6 mo normal
DXA osteoporosis deemed sever or established=
normally pt has experienced one or more Fx
primary HA
not assoc with other diZ likely interplay of genetic, developmental, or environ factors
baby cant retract foreskin
not easily retractable to do until about 3 so normal beforehand dont force it
flumist
not for over age 49 and not if have airway disease
citalopram warning
not too high dose r/t QT prolong even less for older adult SSRI, antidepressant
gest DM tx
nutrition and exercise is 1st line then meds--insulin, sulfonylureas, metformin
>14yo tanner 2 male
nutrition hormonal genetic
>13 thelarche
nutrition, hormonal, genetic etc
tx yeast infxn man (2)
obtain in office glucose- Dx is unusual so check for undiagnosed DM2 topical miconazole
Combo contraceptive for acne
obv female only reduce androgen, dec sebum best for mod-severe need for 3 mo at least but will return when discontinue
most common RF COPD
occupation, smoking, pollution, fam hx, age
days of ABX if not at risk for resistanct
often 5-7 days
Benzoyl peroxide cream/lotion
often found OTC antibacterial tx against acne lower strength 2.5% as effective as 10% and less irritating inexpensive best for mild acne usually with keratolytic acne wash with salicylic acid neutrogena acne wash for example (buy store brand though) combo is just making your own proactiv (they give other shit but the med is this stuff)
when use Sulfonylurea (SU)
often in addition to metformin when second med is needed insulins sensitize with metformin inc availability with SU
derm patient is not systemically ill but miserable
often uncomfortable with itch, burning, pain etc Norwegian scabies, herpes zoster
newborn wt loss
often up to 10% in first week
synagis
often used to prevent RSV in infants born at <35wks
corticosteroids
often used to treat inflammatory and allergic derm disorders mech of action includes immunosuppression and inflammatory properties potency is based on vasoconstrictive activity the most potent steroids, like beclomethasone, have much more vasoconstrictive action hydrocortisone is the least strong
when do people find out they have klinefelter
often when trying to have a kid
type of topical agent with maximal absorption
ointment not gel, lotion, or cream the less viscous, the less absorbed
lumbar spinal stenosis presentation
older standing discomfort leaning on shopping cart pseudoclaudication improves with rest bilat leg numb, weak
extensive dry skin with evidence of lichenification on the plantar aspect of foot
older aging
Giant cell arteritis risk factors
older female of northern european descent
cranial nerves
olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, vestibulocochlear, glossopharyngeal, vagus, accessory, hypoglossal
in hyperthyroidism, what happens to the menstrual
oligomenorrhe
when to take oral Iron with or without food? with milk?
on empty stomach if it bothers take it with food but it minimizes absorption dont take with antacid or milk, prevents from working best
Brudzinski sign
one of the clinical signs of meningitis (PE Neck) A positive sign of meningitis, in which there is an involuntary flexion of the arm, hip, and knee when the patient's neck is passively flexed.
thelarche
onset of breast development 7yo earliest
tanner stage 3
onset of growth spurt penile length darker, coarser heair breast mount labia majora middle finger=pencil penis
rescue therapy for HA
opioids, antiemetics, short course systemic corticosteroids use when standard is ineffective
diverticulitis tx
oral ABX: Cipro or metronidazole
kyphosis is a late sign of
osteoporosis
pregnancy test before contraceptive start?
other than IUD, no problem so how know not preggo no sx of preggo <7d after start of menses no intercource since last menses <7d after abortion 4wks post partfum Breast feed <6mo post partum
when consider screen kids for DMII
overweight/obese and 2 risk factors fam hx, race/ethnicity insulin resistance, acanthosis nigricans, HTN, HLD, PCOS, SGA hx, Mat DM or gest DM
fibromyalgia
pain in the fibrous tissues and muscles
intermittent claudication
pain in the leg muscles that occurs during exercise and is relieved by rest
Knee OA PE
pain, tender, stiff joint dec ROM, crepitus no erythema or warm maybe effustion
pseudoclaudication
painful cramps that are not caused by peripheral artery disease, but rather, by spinal, neurologic, or orthopedic disorders such as spinal stenosis, diabetic neuropathy, or arthritis
open angle glaucoma
painless gradual onset of inc intraocular pressure leading to optic atrophy loss periph if untreated >80% of all glaucoma
varicocele
palpable "nest of worms" scrotal mass that is only evident in standing position
post menopause ovary
palpable is bad
PTH
parathyroid hormone Appropriate body calcium levels too much=hypercalcemia
lachman test
partial or complete tear of ACL
Chronic disease marker Hep B
patient without sx NL or slight elev enz HBsAg (Always Growing)=on board or vax
tanner stage 4
peak of growth spurt most girls before menarche
Diminished bilateral pedal pulses with thinning of the skin
peripheral arterial disease
diminished sensory perceptions and abnormal monofilament examination
peripheral neuropathy can be more than just DM
ASCVD definition
peripheral vascular disease carotid artery disease cerebrovascular disease aortic disease
scabies tx
permethrin even is successful, person usually itches for a few more weeks. You itch until body absorbs the feces in the dead bodies of the organisms
vitamin B12 deficiency
pernicious anemia Increased intake or decreased absorption from GI tract. Anemia s/sx plus red beefy tongue. Neurologic symptoms (paresthesias of extremities). Macrocytic, low reticulocyte count. Treat underlying cause & replace
most common cause of speech delay in early childhood
persistent OME better with fix though mostly
ASD 2 core domains
persistent deficits in social communication and social interaction across multiple contexts with notable deficits- socio/emo, communication, relationships Restricted, repetetive patterns of behavior, interest
Seizure therapies
phenytoin, carbamazepine, clonazepam, ethosuximide, and valproic acid, and more recently developed antiepileptic drugs (AEDs), such as gabapentin, lamotrigine, and topiramate need expert knowledge for AEDs certain AED, phenytoin, carbamazepine have narrow therapeutic index
only acceptable abnormalities during HA and during exam
photophobia and photophonia
Thiazolidinedione example
pioglitazone rosiglitazone
usually preceded by herald patch on the trunk location condition
pityriasis rosea
Why test LP for sepsis
pleocytosis (WBC in CSF) bacterial meningitis (Neutrophil) viral meningitis (lymphocyte)
Why test CXR for sepsis
pneumo dx
systemic vax react
pneumo- fever, myalgia
Pleural inflammation PE findings
pneumonia (late finding with PE but less common) patient report of sharp, localized pain, worse with deep breath, movement, cough Audible pleural friction rub, from movement of inflamed pleura layers -sound similar to stepping on fresh snow
consolidation PE findings
pneumonia dullness to percussion -dense tissue when percussed sounds dull (Dense=Dull) Inc Tactile Fremitus -inc with inc tissue density Bronchial or tubular breath sounds, often with late inspiratory crackles tht do not clear with cough
zoster complications
postherpetic neuralgia, opthamalogic involvement, superimposed bacterial infection
Who should be tx for osteoporosis
postmeno women and men >50 with DXA <-2.5 at femoral neck, total hip, or spine low bone mass or osteopenia -1 to -2.5 at same place and 10y hip Fx prob 3% or all major prob 20+% Hx of hip or vertebral Fx
Macrolide risk
potential QY prolongation inc risk CV death especially if CV risk
SNRI effect
potential energize helpful in Anx, resistant depression lifting mood, inc focus this is what norepi does (focus)
why no naproxen in older adult?
potential fluid retention
Tanner stage 1
pre puberty for both
stages of change
precontemplation, contemplation, preparation, action, maintenance
post infxn cough with QOL intefere severe
prednisone short when other cause have been r/o
live virus precautions
preggo, immune suppression, HIV(<200)
port wine lesion infant presentation
present from birth blanchable (r/t vascular) grows proportionate with child will darken and more nodular as child grow (diff from hemangioma) tend to follow branches of trigeminal nerve
Genital warts tx
prevent with immunization podofilox, liquid nitrogen, cryoprobe, imiquimod preggo watch out
COPD
preventable and treatable dz with some significant extrapulmonary effects that may contribute to its severity in individual patient. its pulmonary component is characterized by airflow limitation that is not fully reversible
Syphilis findings
primary stage: chancre- firm round painless secondary-nonpruritic skin rash- palms soles -fever, lymphadenopathy, sore throat, hair loss, HA, wt loss Latent stage- variabe
18yo with aortic stenosis, why?
prob congenital if ok, will prob need echo every 5 yrs
tx Glaucoma (acute angle-closure intervention)
prompt referral relieve pressure -topical beta adrenergic antagonist -topical alpha 2 agonist -less selective sympathomimetic -topical carbonic anhydrase inhibitors increase fluid outflow -prostaglandin analog miotic agents Sg
pt has a cold and wants to take something but has HTN, what med should he avoid
pseudoephedrine bec it is a vasoconstrictor
anterior surface of knees location condition
psoriasis
drop arm test
pt in sitting with shoulder passively ABD 120 deg. pt instructed to SLOWLY bring arm down to side. (+) pt unable to lower arm slowly back down to side (+) presence of severe pain. Identifies tear and/or full rupture of rotator cuff.
presentation of cutaneous anthrax and tx
pustular skin lesion that eventually forms ulcer with eschar tx- fluoroquinolone and consult
Why test UA for sepsis
pyelonephritits in UTI WBC, bacteria, pos urine culture to detect offending orgs
pyloric stenosis vs intussusception 4:1 M:F
pyloric stenosis
pyloric stenosis vs intussusception olive shaped RUQ abdominal mass occationally
pyloric stenosis
pyloric stenosis vs intussusception post fed projectile vomit and eager to eat post emesis
pyloric stenosis
pyloric stenosis vs intussusception most common time for onset: 3 wks
pyloric stenosis if it can get to 6 wks, they wont get pyloric stenosis
Heart Murmur grade 2
quiet but immediately heard
when to do 24h urine creatinine clearance
r/t serum could be inaccurate for age/body size/veg diet
scale
raised flaking lesion ex: dandruff, psoriasis
plaque
raised lesion, larger than 1 cm, may be same or different color from the surrounding skin ex: psoriasis
Lumbar radiculopathy when specialty eval necessary
rapidly evolving defect persistent neuro defect without resolution after 4-6 wks of conservative tx
blumberg sign
rebound tenderness late finding in peritoneal inflammation
zostavax age
recommended > 60 years old
IBD sx
rectal bleed, diarrhea, fever, wt loss, lab evidence of inflammation- inc CRP or ESR leukocytosis esp during flares
asthma sx
recurrent cough wheeze SOB and/or Chest tight occur or worsen at night, with exercise, viral resp infxns, aeroallergens, pulm irritants
most important source of body's iron supply
recycled iron content from aged RBC so more common with older adults is chronic low volume blood loss (not diet) think where is blood loss, GI tract? etc
eye referral triad
red eye, painful eye, new onset vision change refer to opthamology
when to consider secondary HA
red flags
atopic dermatitis infant present from birth-2yrs
red, crust, extensor, face scalp
goal of asthma therapy
reduce impairment reduce risk optimize health and function
tx Glaucoma (primary chronic open-angle)
reduce production of intraocular fluid -topical beta adrenergic antagonist -topical alpha 2 agonist -less selective sympathomimetic -topical carbonic anhydrase inhibitors -combination solutions available increase fluid outflow -prostaglandin analog miotic agents Sg
goal of COPD tx
reduce sx reduce risk
hyposmia
reduced sense of smell
angle closure glaucoma intervention
refer Acute intervention to block aqueous production, reduce vitreous volume, facilitate aqueous outflow with acetazolamide (Diamox), topical beta blocker and pilocarpine
Healthy 32yo with ASCUS pos and high risk HPV with no hx of pos next step
refer for colposcopy r/t high risk HPV if ASCUS alone, could do repeat on next visit
Anterior Uveitis (Iritis) Intervention
refer opthamology acute tx with topical or systemic steroid and cycloplegics tx etiology as it is often accompanied by autoimmune dz
hyperemic
refers to an excessive amount of blood in a part or area
RBC Hb content
reflected by MCH (mean cell hemoglobin) Hb is source of cells color (chromic) Hb is 90% of RBC volume Normochromic: normal color=MCHC=31-37 Hypochromic=pale=MCHC<31
Stage D HF
refractory HF extreme measure or QOL care
MS classification
relapsing-remitting is 85% of pts primary progressive where they do not fully resolve
non communicating hydrocele, cause, presentation, mgmt
residual fluid in there no change in size reassurance, usually ok at 2yo
Active immunity is defined as
resistance developed in response to an antigen.
med with warning of potential tendon rupture when taken with systemic steroid
respiratory fluoroquinolone but not as bad as a COPD flare which would kill you
paraphimosis
retracted foreskin that cannot be brought forward to cover the glans can be emergency refer
TIA characterization
reversible neuro sx can last 24 hrs
metformin and renal
risk lactic acidosis
saturated fat is solid at
room temperature
Measles
rubeola virus acute present with fever, nasal discharge, cough, gen lymph, conjunctivitis, photophobia, Koplik Spots, pharyngitis, maculopapular rash
trigeminal neuralgia
s/s: facial pain, shoots up cheek with food or drink
vaccines by 1 yr
same as 6 mo MMR VAR Hep A
when delay peds immunization
same as adult mod-severe illness with or without fever
HTN with DM 1st line
same as normal without DM except 140/90 goal no matter age
over waist band location condition
scabies they like where it is warm
seborrheic derm infant
scalp, face, groin, underarm overproduce sebum present with erythema, greasy yellow scales
actinic keratosis
scaly plaque precursor to Squamous cell carcinoma, and is in mostly sun exposed areas
6-12 wks post partum for gest DM
screen DM not A1C
open angle glaucoma screen
screen with tonoometry and visual fields assess
testicular torsion
scrotal pain and loss of cremasteric reflex turned more than 360 deg urological emergency time=testical
when neuroimaging with HA
secondary HA
Knee OA tx conservative
self mgmt- strengthening, low impact aerobic wt loss
Cluster HA
several wks to months then disappear for a long time usually similar time of yr more male than female
Lumbar radiculopathy sx
sharp, burning electric shock sensation worse when inc spinal fluid- this puts pressure on nerve root sneeze, cough, strain evokes pain
chicken pox vs shingles
shingles is mostly >50 or hx of varicella Have to have had chicken pox cant give another person zoster but person with zoster can give non immune person chicken pox zoster not systemic normally varicella start trunk and move to limbs
paroxetine 1/2 life and drug drug potential
short many
premature destruction (hemolytic anemima)
short RBC lifespan <90
Hemic murmur
shows up in absence of cardiac pathology but contact more than normal high fever, profound dehydration, anemia is bad, thyroid toxicosis happens in 3rd trimester of preggo sometimes
Lumbar radiculopathy PE
sign of LS straign altered neuro exam incl straight leg raise, sensory loss, altered DTR
WBC >10,000 anticipated response
significant bacterial infxn like appendicitis, pyelonephritis, bacterial pneumonia noninfectious reasons like stress, pain, environmental extremes
why no Amitryptiline in older adult?
significant orthostatic hypotension risk
ACS in elderly
silent MI common inc with age (60%>85) consider with any acute illness
Secondary hyperparathyroidism clinical presentation
similar to primary moans, groans, stones, and bones with psychic overtones
herald patch
single red, oval scaling lesion
what if a vaccinated person is exposed to HepB
single vaccine booster
Bile acid resins effect
sit in the gut and soak up bile acid and lower LDL
Dipeptidyl peptidase-4 (DPP-4) inhibitor example
sitagliptin (januvia) saxagliptin linagliptin alogliptin
anaphylaxis is likely with one of these 3 conditions
skin and or mucosa AND either respiratory compromise OR BP or end organ dysfunction
keratosis pilaris
skin condition in which white bumps appear on the upper arms, thighs, and cheeks
lichen sclerosis
skin disease, white spots appear over time, most common genital and rectal
lichenification
skin thickening usually found over pruritic or friction areas Ex: seen in areas of recurrent scratching
angle closure glaucoma clinical presentation
slit lamp eval: corneal edema synechiae irreg pupil shape or segmental iris atrophy cornea and scleral injection ciliary flush
in hypothyroidism, what happens to the weight
small gain 5-10lbs, largely fluid
koplik spots
small, blue-white spots with red halo over oral mucosa; early sign of measles
therapeutic goals for COPD non med
smoking cessation phys active flu and pneumo vax pulmonary rehab
in hyperthyroidism, what happens to the skin
smooth silky
NL peak post prandial
so 1-2 hrs post meal 140
Lumbar sacral strain etiology and sx
spasm, irritation of LS supporting muscles spasm, ache, stiff position, activity and rest impacts pain level
what test do we need to make dx of asthma
spirometry peak flow is for monitoring (in practice it is used for dx all the time)
slow growing painless oral lesion
squamous cell carcinoma? biopsy, CT on neck
Tx alzheimer agitation and depression
standard anti depressant
need to wait to start COC?
standard method: Sunday start after menses begin (menses will occur during week not over weekend) THIS IS WITH HORMONE FREE WEEK Use back up for 7 days First day menses start no back up needed QUICK START make sure not preggo start that day use back up for 7 days JUMP START emergency contraception COC that day back up 7 day
1st gen antihistamine examples and mech of action and AE
standard or first generation ex: Benadryl or Chlor-Trimeton 1st gen cross BBB and cause sedation and should be taken with caution. anticholinergic activity can dry secretions, cause visual changes and urinary retention, which is bad for older men with BPH older adults using can have negative cognitive effects
How are systemic antihistamines divided into groups
standard or first generation ex: Benadryl or Chlor-Trimeton newer or 2nd gen ex: Loratidine (Claritin), Clarinex, Cetirizine (Zyrtec), Allegra, Xyzal
12 months remember
stands tall like #1 and walks on 2 legs
teething begin
start thinking about it if not there at 12 mo erupt at around 6-10 mo
tx DM2 monotherapy
start with metformin
HMG-CoA reductase inhibitor example
statins
Heart valve dysfunction 2 ways
stenosis: fail to open adequately incompetent: fail to close adequately -cause regurgitant murmurs
Knee OA tx procedural
steroid inconclusive recc
cover/uncover test is for
strabismus
tenesmus
straining, especially ineffectual and painful straining at stool or in urination
most common form of incont in women
stress incontinence rarely in men
Stage B HF example and definition
structural HD without s/sx of HF pt with prev MI, LV remodeling including LVH and low EF asymptomatic vavlular Dz
TSH inc (8.9) FT4: NL
subclinical hypothyroid AACE recc tx with TSH >5 if: has goiter problems that affect infertility, preggo etc
CYP 450 drug drug interaction
substrate: utilizes a specific enzymatic pathway Viagra, statins, effexor, xanax etc 50% of Rx meds CYP450 3A4 substrate Inhibitor: block specific enzymatic pathway and keeps substrate from exiting Ex: erythro, clarithro, so if you use with 3A4, can inc substrate levels and poss toxicity so simvastatin and erythro is a bad combo risk for Rhabdo Inducer: pushes substrate out exit pathway leads to reduce substrate Ex: St Johns Wort, so with 3A4 can reduce therapeutic effect of the 3A4 Bad mix with select antiretrovirals (HIV drugs), oral contraceptives, cyclosporine (organ rejection)
Angle closure glaucoma
sudden inc in intraocular pressure usually unilateral acute red painful vision change halos eyeball firm in comparison
well controlled asthma
sx <_2d/wk awaken <_2x/mo normal activity ok SABA <_2d/wk FEV>80%
Is it asthma?
sx consistent airflow obstruction that is at least partially reversible consider dx and perform spirometry if any of these indicators are present
moderate persistent asthma >12yo
sx daily awaken=>1x/wk but not nightly SABA=daily normal activity=some limitation lung function: FEV1 60-80% step 3 tx: oral corticosteroids now then low dose ICS+LABA or med dose ICS pref: med dose ICS
when MRI for LBP
sx of radiculopathy after conservative tx pt may need Sg or steroid inj Rf or sx of spinal stenosis
permethrin
synthetic pyrethroid widely used to control ectoparasites
injectible penicillin tx sti
syphillis
aggressive tx of inflammation during asthma flare
systemic corticosteroids ex: prednisone 40-60mg/d 3-10d not injectible (no benefit) taper not necessary inc use of rescue drug during flare
tetanus sx
systemic disease painful muscle weakness spasm (lockjaw) 10% mortality most cases are adults over 50
polymyalgia rheumatica tx
systemic steroid
large joint pain, involuntary wt loss, fatigue systemic or just osteo
systemic with osteo sx
thyroid produces 2 hormones
t4 and t3
holosystolic
takes all of systole and is the same all of systole VSD, tricuspid regurgitation, mitral regurgitation
test ankle instability
talar tilt
stress incontinence tx
tampon urethral stent kegel biofeedback
gynecomastia usually found in tanner stage..
tanner stage 3
start insulin step 1
target fasting glu with basal insulin HS 10 units and inc dose 2 units every 3 days until 70-130
start insulin step 2
target pre meal glu with one meal at a time target 70-130 pre meal use bolus insulin if pre lunch glu >130 start 4 units before breakfast etc start 4 units and inc by 2 every 3 days if necessary
prior to preggo screen for conditions
tay-sachs CF SCD (maybe early)
transient incontinence
temporary or occasional incontinence that is reversed when the cause is treated
acute prostatitis finding
tender, boggy, indurated cheekbone
murphy sign
tenderness in the right subcostal area on inspiration, associated with acute cholecystitis
Fluoroquinolone risk
tendon rupture worst in older adult with concominant systemic corticosteroid and/or select organ transplant
most common primary HA
tension type then Migraine, then Cluster is a distant 3rd
spondyloarthropathy
term that means anyone of the group of inflammatory disorders that affect the joints and spine
snellen chart
test gen visual acuity
crpytorchidism
testicle located in inguinal canal or abdomen common in babies general rule is to wait til 1-2yo
verruca vulgaris
the common wart, caused by HPV, is also called:
galactorrhea
the production of breast milk in a women who is not breastfeeding
oxyhemoglobin dissociation curve
the relationship between hemoglobin saturation and PO2 is shown by ____ curve Relationship between available oxygen and amount of oxygen carried by hemoglobin. low Sa02 is a late sign in asthma flare
perimenopause
the time surrounding menopause; its onset is marked by the beginning symptoms of menopause and ends with the cessation of menses. irreg period hot flashes sleep prob estrogen normal but FSH inc
COPD bronchodilator maybe add on
theophylline as add on
what if partial response to albuterol
there is airway inflammation
acute bronchitis tx
they dont need ABX most likely often given ABX they want to stop coughing consider mucarinic antag bronchodilator (ipratropium) also could use albuterol or short course oral stroid (prenidsone 40 3-5d) but this would be for protracted problematic cough Pref- prednisone, gets rid of inflammation in airways and thats what is causing the cough
medrol dose pack
theyre bullshit
gout triggers
thiazide diuretic consumption of organ meats ETOH
in hypothyroidism, what happens to the skin?
thick dry
acanthosis nigricans
thickened, hyperpigmented skin in the axillae, groin, and skin folds associated with malignancies, obesity, and DM
progestin and estrogen cervical mucus
thickens thins/increase so opposites. Progestin is contraceptive
tinel's sign
tingling and tapping over the median nerve as it enters the carpal tunnel
so why estrogen added to COC
to get a few days of flow
proliferative diabetic retinopathy SX
to support retinal nourishment, new fragile vessels form
calcium recc peds
toddler-500mg 4-8yo=800mg 9-18=1300mg yogurt, greens, peas, tofu, cottage cheese, milk, almonds
glaucoma
too much pressure in eyeball deeply cupped optic disk
papilledema
too much pressure in the brain
firm white 4mm nodular auricular lesion
tophi bec ear is cool
burn basic tx
topical agent and dressing- Bacitracin etc, duoderm etc pain control- 30 min befored dressing promote healing- hydrate, teach clean technique prevent infxn and desiccation
tinea pedis tx
topical ketoconazole
rosacea tx
topical metronidazole not antifungal cuz not conazole
open angle glaucoma tx
topical miotics, BB, Sg maybe
4yo remember
tower 4 block 4 wd sentence draws a cross
intervention in anemia
treat the underlying cause if severe or chronic consider multiple causes replace the micronutrients like Fe or vitamins EPO or Procrit: helpful in severe anemia, especially if renal failure (check GFR if needed)
DIAPPERS
treatable causes of urinary incontinence Delirium Infxn Atrophic urethritis and vaginitis Pharma (diuretics etc) Psycho Excessive urine output (HF, hyperglu) Restricted Mobility Stool impaction
Parkinsons cardinal features
tremor at rest, rigidity, bradykinesia (slowness in the execution of movement), flexed posture, loss of postural reflexes, and masklike facies. At least two of these, with one being tremor at rest or bradykinesia, must be present.
keratocytic in acne tx
tretinoin (retin-A)
oreal metro vag tx
trich or BV
Influenza protection options for a 62-year-old man with hypertension, dyslipidemia, and type 2 diabetes mellitus include receiving:
trivalent inactivated vaccine (TIV) in standard dose via intramuscular injection. This is the typical "flu shot." A quadrivalent inactivated vaccine is also available. injected is not live but the nasal spray is
thiazide diuretics risk
try not to go over 12.5/day monitor Na and K and Mg calcium sparing (so good for osteo risk) not as good with renal
HTN drug ramp up
try to get 1st line to 1/2 -3/4 most mg then add give what you have a month to work at least
most common secondary HA
tumor, intracranial bleeding, inc ICP, meds like nitrates, meningitis, accelerated HTNm giant cell arteritis, viremia, etc
basal insulin
type of insulin that controls glucose production between meals and overnight, is about 50% of daily needs, nearly constant levels
DX of GERD
typical sx of heartburn and regurgitation just H&P, dont need scope etc
antidepressant discontinuation syndrome FINISH
typically with SSRI, SNRI, TCA lasts <7d but not life threatening flu like sx insomnia nausea imabalance sensory disturbance hyper arousal, Head ache should have tapered over 6 wks
malignancy likelyhood of thyroid nodule
unlikely 5%
3 RF for secondary hypertriglyceridemia
untreated hypothyroid poor controlled DM excessive ETOH
etiology- peripheral vision loss
untreated open angle vlaucoma
woman early warning signs MI
unusual fatigue (70%) sleep disturbance (48%) SOB indigestion Anx diaphoresis dizzy CP (30%)
rear facing carseat
up to 2 yo or wt allowed by seat
min recc prenatal visit
up to 28w---Q4wk 28-36wk---Q2wk >36wk---Qwk
stridor
upper airway obstruction
uric acid overproduction vs urate underexcretion
urate underexcretion is 90% of people with gout its made worse with renal insuff, ETOH, diuretics, purine rich foods
reactive arthritis 1st test after come in with sx
urinary test for gono and chlamydia
Alpha-1 Antitrypsin def screen
use if COPD develops in pts of european ancestry under 45 yrs or strong fam hx of COPD
Prophylactic meds for migraine HA indication for use
use of any product 3x/wk 2+ migraines per month with debilitating sx 3+ days poor sx relief from abortive tx
systemic vs topic corticosteroid for phytodermatitis
use systemic if >20% to total body surface, severe rash, impacts face, genitals, hands, impacts occupational function
abortive or acute tx for HA
used to control HA sx
prophylactic or preventing tx for HA
used to minimize risk of HA
peritonsillar abscess
usually bacterial older child or adult hot potato voice, diff swallow uvula deviation maintain airway ENT CONSULT
Triptans for HA
usually just for migraines Selective serotonin receptor agonist inc uptake potential vasoconstrictor so CI with CAD, angina, preggo, or have recently used ergots careful with MAOI and SSRI bec serotonin syndrome can combine with NSAID
SNRI example
vanlafaxine, duloxetine
IZ to avoid with hx of anaphylactic reaction to gelatin, neomycin
varicella zoster
derm patient with systemic illness
varicella, transepidermal necrosis, lyme disease, systemic lupus erythematosus, etc
small pox is caused by
variola virus
inc microalbumin=
vascular damage to the kidneys=need for better BG, lipid, BP control
hyperpigmentation with bilateral ankle edema
venous insufficiency
Genital warts findings
verruca form lesions can be subclinical or unrecognized
Heart Murmur grade 1
very faint
Heart Murmur grade 5
very loud with thrill
pustule
vesicle-like lesion with purulent content ex: impetigo, acne
musical murmur where heard best example
vibratory quality still murmur
neonatal adenovirus infection
viral conjunctivitis cause excess tearing, mild red, URI sx
thyroiditis
viral or autoimmune, postpartum, drug induced, often transient, usually accompanied by thyroid tenderness
croup
viral, allergic in origin, 6mo-5yr support tx
acute bronchitis in peds
viral, short term, self limiting support tx maybe beta2 agonist
causes of AOM
virus: 70% Bacteria+Virus: 66% S.Pneumo is tx target H influenzae M catarrhalis
DM retinopathy with fluid leak or bleed, macular edema presentation and intervention
vision blur floaters, holes, swiss cheese Prevent progression Photocoagulation and vitrectomy if that doesnt work
BF women post partum wants COC
wait 2-3 wks because she is in high prothrombotic state so its the estrogen
2 year old remember
walk up stairs with help builds block tower 2 word sentences 2 step command
1st line intervention for OME
watch/wait 75-90% resolve in 3 mo eval if over 3 mo or if concerns noted for speech, hearing
preferred asthma visit frequency
well control- 3-6 mo not well- 2-6 wks
baby smell sense
well developed
cytosis
went up
how to choose psych med
what is most bothersome sx what med will possibly be helpful in tx the sx primary care writes 80% of all mental health meds usually dose too low and tx for too short
Antimicrobial therapy principles: The decision making process in which the clinician chooses the agent based on patient characteristics and site of infection questions to ask
what is the most likely pathogen causing this infection? what is the spectrum of a given antimicrobial activity? what is the likelihood of resistant pathogen what is the danger if there is treatment failure?
tophi
what is the name for a deposit of uric acid crystals?
menopause definition
when no menstrual period for 12 mo avg 51yo
when does anemia occur
when the insult is severe enough to disturb normal homeostatic mechanisms and exceed reserves
Vaccine associated paralytic poliomyeltitis
when vax given orally, it is live, a little comes out through stool and can be contagious. This is why oral is not done in the US but is still used other places
preterm infant immunize at what schedule
with extrauterine age
COPD flare, when to use CXR
with fever and/or low Sa02 to help rule out concomitant pneumonia
who should get BMD test
women>65 Men>70 younger postmenopausal men 50-65 with Rf for Fx >50 who has broken a bone if have RA or long term steroid
antihistamine
works by blocking histamine-1 receptor sites
most potent lifestyle mod for HTN
wt loss 5-20mmHg per 10kg wt loss then DASH (8-14mmHg) then sodium then physical activity then ETOH
can someone with chronic hep B transmit infection
yes
if mother is HBsAg positive, does baby have risk
yes give hep B immunization and hep B Ig to the newborn
high risk populations that need flu vax
• All children aged 6 through 59 months. • Adults and children who have chronic pulmonary (including asthma) or cardiovascular (except isolated hypertension), renal, hepatic, neurological, hematologic, or metabolic disorders (including diabetes mellitus). Individuals age 50 years of age and older. • Persons who have immunosuppression (including immunosuppression caused by medications or by HIV infection). • Women who are or will be pregnant during the influenza season. • Children and adolescents (aged 6 months - 18 years) who are receiving long-term aspirin therapy and who might be at risk for experiencing Reye's syndrome after influenza virus infection. • Residents of nursing homes and other long-term care facilities. • American Indians/Alaska Natives. • Persons who are morbidly obese (BMI ≥40) kg/m2. • People who live with or care for those at high risk for complications from flu, including: • Healthcare workers. • Household contacts of persons with medical conditions that put them at high risk for complications from the flu. • Household contacts and out of home caregivers of children aged ≤59 months and adults aged ≥50 years, with par- ticular emphasis on vaccinating contacts of children less than 6 months of age. (These children are too young to be vaccinated.)
CN 1-6
• CN I—Olfactory: You have one nose, where CN I resides. Its function contributes to the sense of smell. • CN II—Optic: You have two eyes, where you will find CN II. Function of this CN is vital to vision and visual fields and, in conjunction with CN III, pupillary reaction. • CN III—Oculomotor: CN III, the eye (oculo-) movement (motor) nerve, works with CNs III, IV, and VI (abducens, which helps the eyeball abduct or move). The actions of these CNs are largely responsible for the movement of the eyeball and eyelid. • CN IV—Trochlear: This nerve innervates the superior oblique muscle of the eye. • CN V—Trigeminal: Three (tri) types of sensation (temperature, pain, and tactile) come from this three- branched nerve that covers three territories of the face. For normal corneal reflexes to be present, the afferent limb of the first division of CN V and the effect limb of CN VII need to be intact. • CN VI—Abducens
CN 7-12
• CN VII—Facial: Dysfunction of this nerve gives the characteristic findings of Bell's palsy (facial asymmetry, droop of mouth, absent nasolabial fold, impaired eyelid movement). • CN VIII—Auditory or vestibulocochlear: When this nerve does not function properly, hearing (auditory) or balance is impaired (vestibulocochlear). Rinne's test is part of the evaluation of this CN. • CN IX—Glossopharyngeal: The name of this CN pro- vides a clue that its function affects the tongue (glosso) and throat (pharynx). Along with CN X, the function of this nerve is critical to swallowing, palate elevation, and gustation. • CN X—Vagus: This CN is involved in parasympathetic regulation of multiple organs, including sensing aortic pressure and regulating blood pressure, slowing heart rate, and regulating taste and digestive rate. • CN XI—Accessory or spinal root of the accessory: Function of this CN can be tested by evaluating shoulder shrug and lateral neck rotation. • CN XII—Hypoglossal: Function of this CN is tested by noting movement and protrusion of the tongue.
For HA, unlikely to correlate with abnormal neuroimaging; neuroimaging unlikely to yield helpful clinical information
• Neurological examination normal • Long-standing history of similar headache • "Worst headache of my life"
Stages of change
• Precontemplation: The patient is not interested in change and might be unaware that the problem exists or minimizes the problem's impact. • Contemplation: The patient is considering change and looking at its positive and negative aspects. The person often reports feeling "stuck" with the problem, unable to figure out how to change to solve or minimize the health issue. • Preparation: The patient exhibits some change behaviors or thoughts and often reports feeling that he or she does not have the tools to proceed. • Action: The patient is ready to go forth with change, often takes concrete steps to change, but is often inconsistent with carrying through. • Maintenance/relapse: The patient learns to continue the change and has adopted and embraced the healthy habit. Relapse can occur, however, and the person learns to deal with backsliding.
Things that significantly increase odds of finding abnormality on neuroimaging for HA
• Rapidly increasing headache frequency • History • Dizziness or lack of coordination • Subjective numbness or tingling • Headache causing awakening from sleep • Headache worse with Valsalva maneuver • Accelerating, new-onset headache • Abnormal neurological examination • Increasing age • More likely nonacute finding such as old infarct, atrophy
HA imaging Consensus-based principles
• Testing should be avoided if it would not lead to a change in management • Not recommended if individual no more likely than general population to have significant abnormality • Testing not normally recommended as population policy, although may make sense at individual level (e.g., with patient or provider fear)
